1
|
Kamel MA, Abbas MT, Kanaan CN, Awad KA, Baba Ali N, Scalia IG, Farina JM, Pereyra M, Mahmoud AK, Steidley DE, Rosenthal JL, Ayoub C, Arsanjani R. How Artificial Intelligence Can Enhance the Diagnosis of Cardiac Amyloidosis: A Review of Recent Advances and Challenges. J Cardiovasc Dev Dis 2024; 11:118. [PMID: 38667736 PMCID: PMC11050851 DOI: 10.3390/jcdd11040118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 04/09/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024] Open
Abstract
Cardiac amyloidosis (CA) is an underdiagnosed form of infiltrative cardiomyopathy caused by abnormal amyloid fibrils deposited extracellularly in the myocardium and cardiac structures. There can be high variability in its clinical manifestations, and diagnosing CA requires expertise and often thorough evaluation; as such, the diagnosis of CA can be challenging and is often delayed. The application of artificial intelligence (AI) to different diagnostic modalities is rapidly expanding and transforming cardiovascular medicine. Advanced AI methods such as deep-learning convolutional neural networks (CNNs) may enhance the diagnostic process for CA by identifying patients at higher risk and potentially expediting the diagnosis of CA. In this review, we summarize the current state of AI applications to different diagnostic modalities used for the evaluation of CA, including their diagnostic and prognostic potential, and current challenges and limitations.
Collapse
Affiliation(s)
- Moaz A. Kamel
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | | | | | - Kamal A. Awad
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Nima Baba Ali
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Isabel G. Scalia
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Juan M. Farina
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Milagros Pereyra
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Ahmed K. Mahmoud
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - D. Eric Steidley
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Julie L. Rosenthal
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Chadi Ayoub
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
- Division of Cardiovascular Imaging, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| | - Reza Arsanjani
- Department of Cardiovascular Medicine, Mayo Clinic, Phoenix, AZ 85054, USA
- Division of Cardiovascular Imaging, Mayo Clinic, 5777 East Mayo Boulevard, Phoenix, AZ 85054, USA
| |
Collapse
|
2
|
Alwan L, Benz DC, Cuddy SAM, Dobner S, Shiri I, Caobelli F, Bernhard B, Stämpfli SF, Eberli F, Reyes M, Kwong RY, Falk RH, Dorbala S, Gräni C. Current and Evolving Multimodality Cardiac Imaging in Managing Transthyretin Amyloid Cardiomyopathy. JACC Cardiovasc Imaging 2024; 17:195-211. [PMID: 38099914 DOI: 10.1016/j.jcmg.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/06/2023] [Accepted: 10/18/2023] [Indexed: 01/29/2024]
Abstract
Amyloid transthyretin (ATTR) amyloidosis is a protein-misfolding disease characterized by fibril accumulation in the extracellular space that can result in local tissue disruption and organ dysfunction. Cardiac involvement drives morbidity and mortality, and the heart is the major organ affected by ATTR amyloidosis. Multimodality cardiac imaging (ie, echocardiography, scintigraphy, and cardiac magnetic resonance) allows accurate diagnosis of ATTR cardiomyopathy (ATTR-CM), and this is of particular importance because ATTR-targeting therapies have become available and probably exert their greatest benefit at earlier disease stages. Apart from establishing the diagnosis, multimodality cardiac imaging may help to better understand pathogenesis, predict prognosis, and monitor treatment response. The aim of this review is to give an update on contemporary and evolving cardiac imaging methods and their role in diagnosing and managing ATTR-CM. Further, an outlook is presented on how artificial intelligence in cardiac imaging may improve future clinical decision making and patient management in the setting of ATTR-CM.
Collapse
Affiliation(s)
- Louhai Alwan
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dominik C Benz
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; CV Imaging Program, Cardiovascular Division, Department of Medicine and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; Cardiac Imaging, Department of Cardiology and Nuclear Medicine, Zurich University Hospital, Zurich, Switzerland
| | - Sarah A M Cuddy
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; CV Imaging Program, Cardiovascular Division, Department of Medicine and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Stephan Dobner
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Isaac Shiri
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Federico Caobelli
- University Clinic of Nuclear Medicine, Inselspital, Bern University Hospital, Switzerland
| | - Benedikt Bernhard
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; CV Imaging Program, Cardiovascular Division, Department of Medicine and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Simon F Stämpfli
- Department of Cardiology, Heart Centre Lucerne, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Franz Eberli
- Department of Cardiology, Triemli Hospital (Triemlispital), Zurich, Switzerland
| | - Mauricio Reyes
- Insel Data Science Center, Inselspital, Bern University Hospital, Bern, Switzerland; Artificial Intelligence in Medical Imaging, ARTORG Center for Biomedical Research, University of Bern, Bern, Switzerland
| | - Raymond Y Kwong
- CV Imaging Program, Cardiovascular Division, Department of Medicine and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Rodney H Falk
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Sharmila Dorbala
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; CV Imaging Program, Cardiovascular Division, Department of Medicine and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
| |
Collapse
|
3
|
Chono T, Harada K, Asanuma O. [Incidental Cardiac Uptake in Bone Scintigraphy Establishing a Diagnosis of Transthyretin Amyloid Cardiomyopathy: A Case Report]. Nihon Hoshasen Gijutsu Gakkai Zasshi 2023; 79:1370-1374. [PMID: 37766520 DOI: 10.6009/jjrt.2023-1403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/29/2023]
Abstract
This is a case of a male patient in his 70s undergoing endocrine therapy for castration-resistant prostate cancer. On follow-up, he underwent whole-body bone scintigraphy for bone metastasis surveillance, and incidental cardiac uptake was identified. The findings were reported by the radiologist to the urologist, which was followed by a cardiac consultation. Late gadolinium enhancement magnetic resonance imaging did not detect typical patterns suggestive of cardiac amyloidosis. However, pyrophosphate scintigraphy identified cardiac uptake. These findings were indicative of transthyretin amyloid cardiomyopathy, and we confirmed the diagnosis by endomyocardial biopsy. In about 0.4-2.0 percentage of elderly patients, incidental cardiac uptake in bone scintigraphy has been reported. Bone scintigraphy is the most commonly utilized techniques among all scintigraphies. Thus, it is crucial that radiologists recognize and report the findings to establish a diagnosis of transthyretin amyloid cardiomyopathy.
Collapse
Affiliation(s)
- Taiki Chono
- Division of Radiology and Nuclear Medicine, Sapporo Medical University Hospital
| | - Kohei Harada
- Division of Radiology and Nuclear Medicine, Sapporo Medical University Hospital
| | - Osamu Asanuma
- Division of Radiology and Nuclear Medicine, Sapporo Medical University Hospital
| |
Collapse
|
4
|
Ahluwalia N, Roshankar G, Draycott L, Jimenez-Zepeda V, Fine N, Chan D, Han D, Miller RJH. Diagnostic accuracy of bone scintigraphy imaging for transthyretin cardiac amyloidosis: systematic review and meta-analysis. J Nucl Cardiol 2023; 30:2464-2476. [PMID: 37226006 DOI: 10.1007/s12350-023-03297-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 05/04/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Bone scintigraphy imaging is frequently used to investigate patients with suspected transthyretin cardiac amyloidosis (ATTR-CM). However, the reported accuracy for interpretation approaches has changed over time. We performed a systematic review and meta-analysis to determine the diagnostic accuracy of visual planar grading, heart-to-contralateral (HCL) ratio, and quantitative analysis of SPECT imaging and evaluate reasons for shifts in reported accuracy. METHODS We performed a systematic review to identify studies of the diagnostic accuracy of bone scintigraphy for ATTR-CM from 1990 until February 2023 using PUBMED and EMBASE. Studies were reviewed separately by two authors for inclusion and for risk of bias assessment. Summary receiver operating characteristic curves and operating points were determined with hierarchical modeling. RESULTS Out of a total of 428 identified studies, 119 were reviewed in detail and 23 were included in the final analysis. The studies included a total of 3954 patients, with ATTR-CM diagnosed in 1337 (39.6%) patients and prevalence ranging from 21 to 73%. Visual planar grading and quantitative analysis had higher diagnostic accuracy (.99) than HCL ratio (.96). Quantitative analysis of SPECT imaging had the highest specificity (97%) followed by planar visual grade (96%) and HCL ratio (93%). ATTR-CM prevalence accounted for some of the observed between study heterogeneity. CONCLUSIONS Bone scintigraphy imaging is highly accurate for identifying patients with ATTR-CM, with between study heterogeneity in part explained by differences in disease prevalence. We identified small differences in specificity, which may have important clinical implications when applied to low-risk screening populations.
Collapse
Affiliation(s)
- Nanki Ahluwalia
- Department of Cardiac Sciences, University of Calgary, GAA08, 3230 Hospital Drive NW, Calgary, AB, T2N 2T9, Canada
| | - Golnaz Roshankar
- Department of Cardiac Sciences, University of Calgary, GAA08, 3230 Hospital Drive NW, Calgary, AB, T2N 2T9, Canada
| | - Logan Draycott
- Department of Cardiac Sciences, University of Calgary, GAA08, 3230 Hospital Drive NW, Calgary, AB, T2N 2T9, Canada
| | | | - Nowell Fine
- Department of Cardiac Sciences, University of Calgary, GAA08, 3230 Hospital Drive NW, Calgary, AB, T2N 2T9, Canada
| | - Denise Chan
- Department of Nuclear Medicine, University of Calgary, Calgary, AB, Canada
| | - Donghee Han
- Departments of Medicine (Division of Artificial Intelligence in Medicine), Imaging and Biomedical Sciences Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Robert J H Miller
- Department of Cardiac Sciences, University of Calgary, GAA08, 3230 Hospital Drive NW, Calgary, AB, T2N 2T9, Canada.
| |
Collapse
|
5
|
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.
Collapse
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
| |
Collapse
|
6
|
Te Beek ET, Lafeber A, Postema JWA, Constandse J, Ronner E, Ten Broek MRJ. Feasibility of Left Ventricle Ejection Fraction Calculation Using Electrocardiographically Gated SPECT Acquisition of 99m Tc-HDP Bone Scintigraphy in Cardiac Amyloidosis. Clin Nucl Med 2023; 48:448-450. [PMID: 36800245 DOI: 10.1097/rlu.0000000000004597] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/18/2023]
Abstract
ABSTRACT We performed bone scintigraphy in 6 patients with suspected cardiac amyloidosis. To evaluate feasibility of left ventricle function analysis, we additionally performed electrocardiographically gated SPECT acquisition. The cardiac-gated SPECT data confirmed adequate tracer uptake for automatic myocardial contour determination. LVEF estimations ranged between 24% and 54%. Comparison with LVEF estimations from prior echocardiography generally showed only small differences. In one patient, the LVEF measurements from both methods seemed discordant, probably reflecting actual LVEF worsening, which was confirmed at follow-up echocardiography. Therefore, our results may suggest that cardiac-gated SPECT acquisition at bone scintigraphy can provide meaningful estimates of LVEF.
Collapse
Affiliation(s)
| | | | | | - Jan Constandse
- Cardiology, Reinier de Graaf Hospital, Delft, the Netherlands
| | - Eelko Ronner
- Cardiology, Reinier de Graaf Hospital, Delft, the Netherlands
| | | |
Collapse
|
7
|
Campi C, Briani C, Salvalaggio A, Giraudo C, Cipriani A, Zorzi A, Zucchetta P, Vettor R, Cecchin D. Semi-Quantification of Myocardial Uptake of Bone-Seeking Agents in Suspected Cardiac Amyloidosis. J Cardiovasc Dev Dis 2023; 10:jcdd10050184. [PMID: 37233151 DOI: 10.3390/jcdd10050184] [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: 03/24/2023] [Revised: 04/14/2023] [Accepted: 04/19/2023] [Indexed: 05/27/2023] Open
Abstract
INTRODUCTION Bone scintigraphy has emerged as a key tool for non-invasive etiologic diagnosis of transthyretin (ATTR) cardiac amyloidosis (CA). We focused on a new semi-quantification method (on planar imaging) that could complement the qualitative/visual Perugini scoring system, especially when SPET/CT is not available. MATERIAL AND METHODS We retrospectively/qualitatively evaluated 8674 consecutive, planar 99mTc-biphosphonate scintigraphies (performed for non-cardiac reasons), identifying 68 (0.78%) individuals (mean age 79 ± 7 years, range 62-100 years; female/male ratio 16/52) presenting myocardial uptake. Due to the retrospective nature of the study, no SPET/CT, pathologic or genetic confirmation was obtained. The Perugini scoring system was determined (in patients presenting cardiac uptake) and compared with three newly proposed semi-quantitative indices. We took 349 consecutive bone scintigraphies, qualitatively absent of any cardiac/pulmonary uptake, as "healthy controls" (HC). RESULTS The heart-to-thigh ratio (RHT) and lung-to-thigh ratio (RLT) indices were significantly higher in patients than in HCs (p ≤ 0.0001). There were statistically significant differences for RHT in HCs vs. patients with qualitative Perugini scores of 1 or >1 (with p ranging from ≤0.001 to ≤0.0001). ROC curves showed that RHT outperformed the other indices and was more accurate in both male and female groups. Furthermore, in the male population, RHT accurately distinguished HCs and patients with scores of 1 (less likely affected by ATTR) from patients with qualitative scores >1 (more likely affected by ATTR) with an AUC of 99% (sensitivity: 95%; specificity: 97%). CONCLUSION The proposed semi-quantitative RHT index can accurately/semi-quantitatively distinguish between HCs and subjects probably affected by CA (Perugini scores from 1 to 3), and could be particularly useful when no SPET/CT data are available (such as in retrospective studies and data mining). Furthermore, RHT can semi-quantitatively predict, with very high accuracy, subjects in the male population more likely to be affected by ATTR. The present study, although using a very large sample, is however retrospective, monocentric, and therefore the generalizability of the results should be proved by an accurate external validation. ADVANCES IN KNOWLEDGE The proposed heart-to-thigh ratio (RHT) can distinguish healthy controls and subjects that are probably affected by cardiac amyloidosis in a simple and more reproducible way, as compared to standard qualitative/visual evaluation.
Collapse
Affiliation(s)
- Cristina Campi
- Department of Mathematics, University of Genoa, 16126 Genoa, Italy
| | - Chiara Briani
- Department of Neurosciences (DNS), University of Padua, 35128 Padua, Italy
| | | | - Chiara Giraudo
- Nuclear Medicine Unit, Department of Medicine-DIMED, Padua University Hospital, 35128 Padua, Italy
| | - Alberto Cipriani
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padua University Hospital, 35128 Padua, Italy
| | - Alessandro Zorzi
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, Padua University Hospital, 35128 Padua, Italy
| | - Pietro Zucchetta
- Nuclear Medicine Unit, Department of Medicine-DIMED, Padua University Hospital, 35128 Padua, Italy
| | - Roberto Vettor
- Internal Medicine Unit, Department of Medicine-DIMED, Padua University Hospital, 35128 Padua, Italy
| | - Diego Cecchin
- Nuclear Medicine Unit, Department of Medicine-DIMED, Padua University Hospital, 35128 Padua, Italy
| |
Collapse
|
8
|
Noborn F, Thomsen C, Vorontsov E, Bobbio E, Sihlbom C, Nilsson J, Polte CL, Bollano E, Vukusic K, Sandstedt J, Dellgren G, Karason K, Oldfors A, Larson G. Subtyping of cardiac amyloidosis by mass spectrometry-based proteomics of endomyocardial biopsies. Amyloid 2023; 30:96-108. [PMID: 36209425 DOI: 10.1080/13506129.2022.2127088] [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] [Indexed: 11/01/2022]
Abstract
BACKGROUND Cardiac amyloidosis is a severe condition leading to restrictive cardiomyopathy and heart failure. Mass spectrometry-based methods for cardiac amyloid subtyping have become important diagnostic tools but are currently used only in a few reference laboratories. Such methods include laser-capture microdissection to ensure the specific analysis of amyloid deposits. Here we introduce a direct proteomics-based method for subtyping of cardiac amyloidosis. METHODS Endomyocardial biopsies were retrospectively analysed from fresh frozen material of 78 patients with cardiac amyloidosis and from 12 biopsies of unused donor heart explants. Cryostat sections were digested with trypsin and analysed with liquid chromatography - mass spectrometry, and data were evaluated by proteomic software. RESULTS With a diagnostic threshold set to 70% for each of the four most common amyloid proteins affecting the heart (LC κ, LC λ, TTR and SAA), 65 of the cases (87%) could be diagnosed, and of these, 61 cases (94%) were in concordance with the original diagnoses. The specimens were also analysed for the summed intensities of the amyloid signature proteins (ApoE, ApoA-IV and SAP). The intensities were significantly higher (p < 0.001) for all assigned cases compared with controls. CONCLUSION Cardiac amyloidosis can be successfully subtyped without the prior enrichment of amyloid deposits with laser microdissection.
Collapse
Affiliation(s)
- Fredrik Noborn
- Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Christer Thomsen
- Department of Clinical Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Egor Vorontsov
- Proteomics Core Facility, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Emanuele Bobbio
- Department of Cardiology, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Carina Sihlbom
- Proteomics Core Facility, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Jonas Nilsson
- Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.,Proteomics Core Facility, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
| | - Christian L Polte
- Institute of Medicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.,Department of Clinical Physiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Entela Bollano
- Department of Cardiology, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kristina Vukusic
- Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.,Department of Clinical Chemistry, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Joakim Sandstedt
- Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.,Department of Clinical Chemistry, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Göran Dellgren
- Department of Cardiothoracic Surgery and Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Kristjan Karason
- Department of Cardiology, Sahlgrenska Academy, University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Anders Oldfors
- Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.,Department of Clinical Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Göran Larson
- Department of Laboratory Medicine, Institute of Biomedicine, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden.,Department of Clinical Chemistry, Sahlgrenska University Hospital, Gothenburg, Sweden
| |
Collapse
|
9
|
Salvalaggio A, Cipriani A, Righetto S, Artioli P, Sinigiani G, De Michieli L, Cason M, Pilichou K, Cecchin D, Briani C. Incidental cardiac uptake of 99mTc-diphosphonates is predictive of poor outcome: data from 9616 bone scintigraphies. J Nucl Cardiol 2022; 29:3419-3425. [PMID: 35437680 DOI: 10.1007/s12350-022-02961-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 02/27/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Bone scintigraphy (BS) is highly diagnostic for amyloid transthyretin (ATTR) cardiomyopathy. Prevalence and prognostic value of BS cardiac uptake is not well established. Our aim was to assess the prevalence of subclinical cardiac ATTR amyloidosis in patients undergoing [99mTc]MDP/DPD scintigraphy and to define their phenotype and prognosis. METHODS AND RESULTS BS scans performed for any clinical indications from 2009 to 2020 were reviewed. Patients were stratified according to Perugini visual score of cardiac uptake. Follow-up data were collected. Among 9616 BS scans, 0.7% (n = 67) showed cardiac uptake. In 47 (70%) patients, Perugini score was 1 and in 20 (30%) patients uptake was ≥ 2, suggesting cardiac ATTR amyloidosis. Forty subjects (61%) died during the follow-up (mean 47 ± 30 months). Compared with patients with Perugini score 1, those Perugini score ≥ 2 showed increased death rate (P = .018). Two (2/67) subjects were investigated for TTR gene mutations resulting negative. CONCLUSIONS In patients undergoing BS for different clinical indications, cardiac uptake suggesting cardiac ATTR amyloidosis is a rare, but still neglected finding, thus preventing possible diagnosis of ATTR cardiomyopathy. Importantly, cardiac uptake negatively affects the survival. Physicians should be aware of this rare, but crucial finding for timely diagnosis and treatment.
Collapse
Affiliation(s)
- A Salvalaggio
- Department of Neurosciences, University of Padova, Via Giustiniani 5, 35128, Padua, Italy
- Padova Neuroscience Center (PNC), University of Padova, Padua, Italy
| | - A Cipriani
- Department of Cardio- Thoraco-Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - S Righetto
- Department of Neurosciences, University of Padova, Via Giustiniani 5, 35128, Padua, Italy
| | - P Artioli
- Department of Medicine (DIMED), Nuclear Medicine Unit, University-Hospital of Padova, Padua, Italy
| | - G Sinigiani
- Department of Cardio- Thoraco-Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - L De Michieli
- Department of Cardio- Thoraco-Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - M Cason
- Department of Cardio- Thoraco-Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - K Pilichou
- Department of Cardio- Thoraco-Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - D Cecchin
- Department of Medicine (DIMED), Nuclear Medicine Unit, University-Hospital of Padova, Padua, Italy
| | - C Briani
- Department of Neurosciences, University of Padova, Via Giustiniani 5, 35128, Padua, Italy.
| |
Collapse
|
10
|
Miller EJ, Campisi R, Shah NR, McMahon S, Cuddy S, Gallegos-Kattan C, Maurer MS, Damy T, Slart RHJA, Bhatia K, Einstein AJ. Radiopharmaceutical supply disruptions and the use of 99mTc-hydroxymethylene diphosphonate as an alternative to 99mTc-pyrophosphate for the diagnosis of transthyretin cardiac amyloidosis: An ASNC Information Statement. J Nucl Cardiol 2022; 29:2748-2760. [PMID: 35838892 PMCID: PMC9285188 DOI: 10.1007/s12350-022-03059-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 06/23/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Edward J Miller
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Roxana Campisi
- Diagnóstico Maipú and Instituto Argentino de Diagnóstico y Tratamiento S.A, Buenos Aires, Argentina
| | - Nishant R Shah
- Division of Cardiology, Department of Medicine, Brown University Alpert Medical School, Providence, RI, USA
| | - Sean McMahon
- Hartford HealthCare Heart & Vascular Institute, Hartford Hospital, Hartford, CT, USA
| | - Sarah Cuddy
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Mathew S Maurer
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, NY, USA
| | - Thibaud Damy
- Department of Cardiology, Université Paris-Est Créteil Val de Marne, Université Paris, Paris, France
| | - Riemer H J A Slart
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Centre, University Medical Center Groningen, Groningen, The Netherlands
| | - Ketan Bhatia
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, NY, USA
| | - Andrew J Einstein
- Seymour, Paul, and Gloria Milstein Division of Cardiology, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, 622 West 168th Street PH 10-203, New York, NY, 10032, USA.
- Department of Radiology, Columbia University Irving Medical Center and NewYork-Presbyterian Hospital, New York, NY, USA.
| |
Collapse
|
11
|
Santarelli MF, Genovesi D, Scipioni M, Positano V, Favilli B, Giorgetti A, Vergaro G, Landini L, Emdin M, Marzullo P. Cardiac amyloidosis characterization by kinetic model fitting on [18F]florbetaben PET images. J Nucl Cardiol 2022; 29:1919-1932. [PMID: 33864226 DOI: 10.1007/s12350-021-02608-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Accepted: 03/11/2021] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To evaluate the feasibility of kinetic modeling-based approaches from [18F]-Flobetaben dynamic PET images as a non-invasive diagnostic method for cardiac amyloidosis (CA) and to identify the two AL- and ATTR-subtypes. METHODS AND RESULTS Twenty-one patients with diagnoses of CA (11 patients with AL-subtype and 10 patients with ATTR-subtype of CA) and 15 Control patients with no-CA conditions underwent PET/CT imaging after [18F]Florbetaben bolus injection. A two-tissue-compartment (2TC) kinetic model was fitted to time-activity curves (TAC) obtained from left ventricle wall and left atrium cavity ROIs to estimate kinetic micro- and macro-parameters. Combinations of kinetic parameters were evaluated with the purpose of distinguishing Control subjects and CA patients, and to correctly label the last ones as AL- or ATTR-subtype. Resulting sensitivity, specificity, and accuracy for Control subjects were: 0.87, 0.9, 0.89; as far as CA patients, the sensitivity, specificity, and accuracy were respectively 0.9, 1, and 0.97 for AL-CA patients and 0.9, 0.92, 0.97 for ATTR-CA patients. CONCLUSION Pharmacokinetic analysis based on a 2TC model allows cardiac amyloidosis characterization from dynamic [18F]Florbetaben PET images. Estimated model parameters allows to not only distinguish between Control subjects and patients, but also between AL- and ATTR-amyloid patients.
Collapse
Affiliation(s)
- M F Santarelli
- CNR Institute of Clinical Physiology, CNR Research Area - Via Moruzzi, 1, 56124, Pisa, Italy.
- Fondazione Toscana "G. Monasterio", Pisa, Italy.
| | - D Genovesi
- Fondazione Toscana "G. Monasterio", Pisa, Italy
| | - M Scipioni
- CNR Institute of Clinical Physiology, CNR Research Area - Via Moruzzi, 1, 56124, Pisa, Italy
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - V Positano
- Fondazione Toscana "G. Monasterio", Pisa, Italy
| | - B Favilli
- Fondazione Toscana "G. Monasterio", Pisa, Italy
| | - A Giorgetti
- Fondazione Toscana "G. Monasterio", Pisa, Italy
| | - G Vergaro
- Scuola Universitaria Superiore 'S. Anna", Pisa, Italy
| | - L Landini
- Fondazione Toscana "G. Monasterio", Pisa, Italy
- Dipartimento di Ingegneria dell'Informazione: DII, Pisa University, Pisa, Italy
| | - M Emdin
- Fondazione Toscana "G. Monasterio", Pisa, Italy
- Scuola Universitaria Superiore 'S. Anna", Pisa, Italy
| | - P Marzullo
- Fondazione Toscana "G. Monasterio", Pisa, Italy
| |
Collapse
|
12
|
Bay K, Gustafsson F, Maiborg M, Bagger‐Bahnsen A, Strand AM, Pilgaard T, Poulsen SH. Suspicion, screening, and diagnosis of wild-type transthyretin amyloid cardiomyopathy: a systematic literature review. ESC Heart Fail 2022; 9:1524-1541. [PMID: 35343098 PMCID: PMC9065854 DOI: 10.1002/ehf2.13884] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 02/11/2022] [Accepted: 02/25/2022] [Indexed: 01/15/2023] Open
Abstract
Wild-type transthyretin amyloid cardiomyopathy (ATTRwt CM) is a more common disease than previously thought. Awareness of ATTRwt CM and its diagnosis has been challenged by its unspecific and widely distributed clinical manifestations and traditionally invasive diagnostic tools. Recent advances in echocardiography and cardiac magnetic resonance (CMR), non-invasive diagnosis by bone scintigraphy, and the development of disease-modifying treatments have resulted in an increased interest, reflected in multiple publications especially during the last decade. To get an overview of the scientific knowledge and gaps related to patient entry, suspicion, diagnosis, and systematic screening of ATTRwt CM, we developed a framework to systematically map the available evidence of (i) when to suspect ATTRwt CM in a patient, (ii) how to diagnose the disease, and (iii) which at-risk populations to screen for ATTRwt CM. Articles published between 2010 and August 2021 containing part of or a full diagnostic pathway for ATTRwt CM were included. From these articles, data for patient entry, suspicion, diagnosis, and screening were extracted, as were key study design and results from the original studies referred to. A total of 50 articles met the inclusion criteria. Of these, five were position statements from academic societies, while one was a clinical guideline. Three articles discussed the importance of primary care providers in terms of patient entry, while the remaining articles had the cardiovascular setting as point of departure. The most frequently mentioned suspicion criteria were ventricular wall thickening (44/50), carpal tunnel syndrome (42/50), and late gadolinium enhancement on CMR (43/50). Diagnostic pathways varied slightly, but most included bone scintigraphy, exclusion of light-chain amyloidosis, and the possibility of doing a biopsy. Systematic screening was mentioned in 16 articles, 10 of which suggested specific at-risk populations for screening. The European Society of Cardiology recommends to screen patients with a wall thickness ≥12 mm and heart failure, aortic stenosis, or red flag symptoms, especially if they are >65 years. The underlying evidence was generally good for diagnosis, while significant gaps were identified for the relevance and mutual ranking of the different suspicion criteria and for systematic screening. Conclusively, patient entry was neglected in the reviewed literature. While multiple red flags were described, high-quality prospective studies designed to evaluate their suitability as suspicion criteria were lacking. An upcoming task lies in defining and evaluating at-risk populations for screening. All are steps needed to promote early detection and diagnosis of ATTRwt CM, a prerequisite for timely treatment.
Collapse
Affiliation(s)
- Katrine Bay
- Bay WritingCopenhagenDenmark
- Pfizer DenmarkBallerupDenmark
| | - Finn Gustafsson
- The Heart CenterCopenhagen University Hospital, RigshospitaletCopenhagenDenmark
| | - Michael Maiborg
- Odense Amyloidosis Center & Department of CardiologyOdense University HospitalOdenseDenmark
| | | | | | | | | |
Collapse
|
13
|
Bellevre D, Bailliez A, Delelis F, Blaire T, Agostini D, Mouquet F, Maréchaux S, Manrique A. Quantitation of myocardial 99mTc-HMDP uptake with new SPECT/CT cadmium zinc telluride (CZT) camera in patients with transthyretin-related cardiac amyloidosis: Ready for clinical use? J Nucl Cardiol 2022; 29:506-514. [PMID: 32715418 DOI: 10.1007/s12350-020-02274-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 06/14/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND The aim of this study was to investigate the feasibility of assessing absolute myocardial 99mTc-HMDP uptake in patients with suspected cardiac ATTR using SUV with a whole-body CZT SPECT-CT camera (DNM670CZT). METHODS Fifteen patients with suspected cardiac ATTR (Perugini ≥ 2) underwent a conventional 99mTc-HMDP planar imaging and a thoracic SPECT/CT using a DNM 670CZT. A control group consisted of 15 patients with negative scintigraphy (Perugini < 2). SUVmax (mg·L-1) and percentage of injected dose (%ID) were calculated in a cardiac volume of interest (VOI) encompassing the left ventricle. VOIs were also placed in the lung, the right pectoris major, and the sternum. A heart-to-lung SUVmax ratio (HLR) was calculated. RESULTS All ATTR patients demonstrated an increased cardiac HMDP SUVmax (12.2 ± 3.7 mg·L-1) vs controls (3.5 ± 1.2, P < .0001). Percentage of ID, pectoral uptake and HLR were significantly higher in the ATTR group (1.1 ± 0.3 vs 0.15 ± 0.8, P < .0001; 1.5 ± 0.3 vs 0.9 ± 0.3, P < .0001; 9.7 ± 3 vs 4.3 ± 2.2, P < .0001). Bone uptake was not statistically different between the two groups. CONCLUSION This study demonstrated the feasibility of quantitative 99mTc-HMDP SUVmax measurement using a whole-body SPECT/CT CZT camera in patients with suspected cardiac ATTR.
Collapse
Affiliation(s)
- Dimitri Bellevre
- Normandie Univ, UNICAEN, Signalisation, électrophysiologie et imagerie des lésions d'ischémie-reperfusion myocardique, FHU REMOD-VHF, Caen, France.
- Department of Nuclear Medicine, UF 5881, Groupement des Hôpitaux de l'Institut Catholique de Lille, Lomme, France.
- Department of Nuclear Medicine, IRIS, Hôpital Privé Le Bois, Lille, France.
| | - Alban Bailliez
- Department of Nuclear Medicine, UF 5881, Groupement des Hôpitaux de l'Institut Catholique de Lille, Lomme, France
- Department of Nuclear Medicine, IRIS, Hôpital Privé Le Bois, Lille, France
| | - François Delelis
- Department of Cardiology, Groupement des Hopitaux de l'instituts catholiques de Lille, Lomme, France
| | - Tanguy Blaire
- Department of Nuclear Medicine, UF 5881, Groupement des Hôpitaux de l'Institut Catholique de Lille, Lomme, France
- Department of Nuclear Medicine, IRIS, Hôpital Privé Le Bois, Lille, France
| | - Denis Agostini
- Normandie Univ, UNICAEN, Signalisation, électrophysiologie et imagerie des lésions d'ischémie-reperfusion myocardique, FHU REMOD-VHF, Caen, France
- Department of Nuclear Medicine, CHU Cote de Nacre, Normandy University, Caen, France
| | | | - Sylvestre Maréchaux
- Department of Cardiology, Groupement des Hopitaux de l'instituts catholiques de Lille, Lomme, France
| | - Alain Manrique
- Normandie Univ, UNICAEN, Signalisation, électrophysiologie et imagerie des lésions d'ischémie-reperfusion myocardique, FHU REMOD-VHF, Caen, France
- Department of Nuclear Medicine, CHU Cote de Nacre, Normandy University, Caen, France
| |
Collapse
|
14
|
Santarelli MF, Genovesi D, Positano V, Di Sarlo R, Scipioni M, Giorgetti A, Landini L, Marzullo P. Cardiac amyloidosis detection by early bisphosphonate (99mTc-HMDP) scintigraphy. J Nucl Cardiol 2022; 29:307-318. [PMID: 32596791 DOI: 10.1007/s12350-020-02239-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 06/09/2020] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To determine one or more indexes able to detect the presence of cardiac amyloidosis (CA) from planar scintigraphy images after injection of 99mTc-HMDP tracer and to identify the earliest acquisition time able to ensure an accurate diagnosis of amyloid transthyretin CA. METHODS AND RESULTS A total of 38 patients were included: 18 subjects with a final diagnosis of ATTR-CA and 20 controls. Dynamic planar images of the anterior thorax were acquired, starting at intravenous injection of ≈ 700 MBq of 99mTc-HMDP. From time/activity curves (TAC) of regions of interest such as heart, vascular region, right ribcage, and soft tissues, several indices were considered. From the analysis, it resulted that both TACHeart/Bone(t) and RIheart-bone(t), for t > 6 minutes, well distinguish ATTR-CA patients from controls subjects. This is confirmed by the area under curves (AUC) analysis giving AUC values =.9 at t ≅ 6 minutes and AUC ≅ 1 for t > 10 minutes. CONCLUSIONS The method proposed allows determining the presence of ATTR-CA, in an inexpensive manner both in terms of examination costs and time spent.
Collapse
Affiliation(s)
- M F Santarelli
- CNR Institute of Clinical Physiology, CNR Research Area, Via Moruzzi 1, 56124, Pisa, Italy.
- Fondazione Toscana "G. Monasterio", CNR Research Area, Via Moruzzi 1, Pisa, Italy.
| | - D Genovesi
- Fondazione Toscana "G. Monasterio", CNR Research Area, Via Moruzzi 1, Pisa, Italy
| | - V Positano
- Fondazione Toscana "G. Monasterio", CNR Research Area, Via Moruzzi 1, Pisa, Italy
| | - R Di Sarlo
- Dipartimento di Ingegneria dell'Informazione: DII, Pisa University, Via Caruso 16, Pisa, Italy
| | - M Scipioni
- CNR Institute of Clinical Physiology, CNR Research Area, Via Moruzzi 1, 56124, Pisa, Italy
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - A Giorgetti
- Fondazione Toscana "G. Monasterio", CNR Research Area, Via Moruzzi 1, Pisa, Italy
| | - L Landini
- Fondazione Toscana "G. Monasterio", CNR Research Area, Via Moruzzi 1, Pisa, Italy
- Dipartimento di Ingegneria dell'Informazione: DII, Pisa University, Via Caruso 16, Pisa, Italy
| | - P Marzullo
- Fondazione Toscana "G. Monasterio", CNR Research Area, Via Moruzzi 1, Pisa, Italy
| |
Collapse
|
15
|
Cuscaden C, Ramsay SC, Prasad S, Goodwin B, Smith J. Estimation of prevalence of transthyretin (ATTR) cardiac amyloidosis in an Australian subpopulation using bone scans with echocardiography and clinical correlation. J Nucl Cardiol 2021; 28:2845-2856. [PMID: 32385832 DOI: 10.1007/s12350-020-02152-x] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2019] [Accepted: 04/05/2020] [Indexed: 01/08/2023]
Abstract
BACKGROUND Bone scans differentiate transthyretin (ATTR) cardiac amyloidosis from light chain amyloidosis and other causes of increased left ventricular (LV) wall thickness. We examined the prevalence and implications of cardiac uptake in the general population. METHODS Patients were included based on having undertaken a bone scan for non-cardiac indications using Technetium 99m hydroxymethylene diphosphonate (HMDP) or Technetium 99m methylene diphosphonate (MDP). Blinded image review was undertaken. Positive was defined as cardiac uptake ≥ rib AND heart/whole body ratio (H/WB) > 0.0388. Echocardiography and clinical records were reviewed. RESULTS 6918 patients were included. 15/3472 HMDP scans were positive (14 males, 1 female): none in individuals aged < 65; 1.44% in males and 0.17% in females ≥ 65; 6.15% in males and 1.69% in females ≥ 85. Only 1/3446 MDP scans were positive. All HMDP positive patients had increased septal wall thickness on echocardiography. H/WB correlated positively with LV mass, and negatively with LV ejection fraction. No individual had an explanation other than ATTR for their positive scan. CONCLUSION In this Australian subpopulation, the prevalence of positive bone scans consistent with cardiac ATTR is 0% in individuals aged < 65. Prevalence increased with age, reaching 6.15% in men ≥ 85. The amount of HMDP uptake correlated with echocardiographic features of more advanced cardiac involvement. MDP does not appear useful in ATTR.
Collapse
Affiliation(s)
- Claire Cuscaden
- Department of Medical Imaging, Princess Alexandra Hospital, 199 Ipswich Rd, Woolloongabba, QLD, 4102, Australia
- Faculty of Medicine, University of Queensland, St Lucia, Australia
| | - Stuart C Ramsay
- Department of Nuclear Medicine and Specialised PET Service, Royal Brisbane and Women's Hospital (RBWH), Ned Hanlon Building, Herston, QLD, 4029, Australia.
- School of Medicine, James Cook University, 1 James Cook Dr, Douglas, QLD, 4814, Australia.
| | - Sandhir Prasad
- Department of Cardiology, RBWH, Herston, QLD, 4029, Australia
| | - Bruce Goodwin
- Department of Nuclear Medicine, Queensland Children's Hospital, 501 Stanley St, South Brisbane, QLD, 4101, Australia
| | - Jye Smith
- Department of Nuclear Medicine and Specialised PET Service, Royal Brisbane and Women's Hospital (RBWH), Ned Hanlon Building, Herston, QLD, 4029, Australia
| |
Collapse
|
16
|
Zhao H, Hu H, Cui W. Performance of bone tracer for diagnosis and differentiation of transthyretin cardiac amyloidosis: a systematic review and meta-analysis. DIAGNOSTIC AND INTERVENTIONAL RADIOLOGY (ANKARA, TURKEY) 2021; 27:802-810. [PMID: 34792038 DOI: 10.5152/dir.2021.20662] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE Bone tracers have been validated for many years in detecting transthyretin cardiac amyloidosis (TTR-CA). However, several new studies suggest conflicting results. Our study aimed to systematically evaluate the accuracy of bone radiotracers for diagnosis and differentiation of TTR-CA via a systematic review and meta-analysis. METHODS We retrieved articles assessing the performance of bone tracer in diagnosing and differentiating TTR-CA from PubMed, the Cochrane Library, ScienceDirect, and DOAJ databases, dating up to 10 July 2020. The meta-analysis was conducted through Stata 16 software, and the risk of bias for the included studies was assessed by the QUADAS-2 tool. Moreover, we made a comprehensive review. RESULTS Fourteen articles were included in the systematic review, and 9 in the meta-analysis. The pooled sensitivity was 0.97 (95% confidence interval [95% CI] 0.85-0.99) with heterogeneity (I2=73.5, 95% CI 55.6-91.2), and the specificity was 0.92 (95% CI 0.82-0.96) with heterogeneity (I2=42.0, 95% CI 0.0-86.9). The pooled positive and negative likelihood ratios were 11.49 (95% CI 5.07-26.0) and 0.03 (95% CI 0.01-0.18), respectively. The diagnostic odds ratio was 341 (95% CI 53-2194), and the area under the receiver operating characteristic curve was 0.96 (95% CI 0.94-0.97). CONCLUSION The findings evidence that the bone radiotracer is a valuable noninvasive approach that provides high accuracy for diagnosing TTR-CA and plays a modest role in differentiating TTR-CA from immunoglobulin amyloid light-chain cardiac amyloidosis. 99mTc-HMDP may be more accurate than 99mTc-PYP, 99mTc-DPD, and 18F-NaF in the TTR-CA detecting process, and 18F-NaF is a promising bone tracer to diagnose and differentiate TTR-CA.
Collapse
Affiliation(s)
- Hongliang Zhao
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China;Institute of Cardiocerebrovascular Disease of Hebei Province, Shijiazhuang, China; Department of Cardiology, The First Hospital of Hebei Medical University, Shijiazhuang, China
| | - Haijuan Hu
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China; Institute of Cardiocerebrovascular Disease of Hebei Province, Shijiazhuang, China
| | - Wei Cui
- Department of Cardiology, The Second Hospital of Hebei Medical University, Shijiazhuang, China;Institute of Cardiocerebrovascular Disease of Hebei Province, Shijiazhuang, China
| |
Collapse
|
17
|
Ruan D, Sun L. Diagnostic efficacy of bone scintigraphy in transthyretin cardiac amyloidosis: an updated systematic review and Bayesian bivariate meta-analysis. Clin Transl Imaging 2021. [DOI: 10.1007/s40336-021-00471-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
|
18
|
99mTechnetium-labeled cardiac scintigraphy for suspected amyloidosis: a review of current and future directions. Heart Fail Rev 2021; 27:1493-1503. [PMID: 34709500 DOI: 10.1007/s10741-021-10174-x] [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: 09/16/2021] [Indexed: 10/20/2022]
Abstract
Cardiac amyloidosis (CA) is an underdiagnosed form of restrictive cardiomyopathy leading to a rapid progression into heart failure. Evaluation of CA requires a multimodality approach making use of echocardiography, cardiac magnetic imaging, and nuclear imaging. Technetium (Tc)-labeled cardiac scintigraphy has witnessed a resurgence in its application for the workup of CA. Advancements in disease-modifying therapies have fueled the rapid adoption of cardiac scintigraphy using bone tracers and the need for transformative novel studies. The goal of this review is to present diagnostic utility, currently recommended protocols, as well as a glimpse into the rapid evolution of Tc-labeled cardiac scintigraphy in the diagnosis of CA.
Collapse
|
19
|
Wu Z, Yu C. Diagnostic performance of CMR, SPECT, and PET imaging for the detection of cardiac amyloidosis: a meta-analysis. BMC Cardiovasc Disord 2021; 21:482. [PMID: 34620092 PMCID: PMC8499558 DOI: 10.1186/s12872-021-02292-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 09/17/2021] [Indexed: 12/24/2022] Open
Abstract
Background Noninvasive myocardial imaging modalities, such as cardiac magnetic resonance (CMR), single photon emission computed tomography (SPECT), and Positron emission tomography (PET), are well-established and extensively used to detect cardiac amyloid (CA). The purpose of this study is to directly compare CMR, SPECT, and PET scans in the diagnosis of CA, and to provide evidence for further scientific research and clinical decision-making. Methods PubMed, Embase, and Cochrane Library were searched. Studies used CMR, SPECT and/or PET for the diagnosis of CA were included. Pooled sensitivity, specificity, positive and negative likelihood ratio (LR), diagnostic odds ratio (DOR), their respective 95% confidence intervals (CIs) and the area under the summary receiver operating characteristic (SROC) curve (AUC) were calculated. Quality assessment of included studies was conducted. Results A total of 31 articles were identified for inclusion in this meta-analysis. The pooled sensitivities of CMR, SPECT and PET were 0.84, 0.98 and 0.78, respectively. Their respective overall specificities were 0.87, 0.92 and 0.95. Subgroup analysis demonstrated that 99mTc-HMDP manifested the highest sensitivity (0.99). 99mTc-PYP had the highest specificity (0.95). The AUC values of 99mTc-DPD, 99mTc-PYP, 99mTc-HMDP were 0.89, 0.99, and 0.99, respectively. PET scan with 11C-PIB demonstrated a pooled sensitivity of 0.91 and specificity of 0.97 with an AUC value of 0.98. Conclusion Our meta-analysis reveals that SEPCT scans present better diagnostic performance for the identification of CA as compared with other two modalities. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-021-02292-z.
Collapse
Affiliation(s)
- Zhaoye Wu
- Department of Nuclear Medicine, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Chunjing Yu
- Department of Nuclear Medicine, Affiliated Hospital of Jiangnan University, Wuxi, China.
| |
Collapse
|
20
|
Santarelli MF, Scipioni M, Genovesi D, Giorgetti A, Marzullo P, Landini L. Imaging Techniques as an Aid in the Early Detection of Cardiac Amyloidosis. Curr Pharm Des 2021; 27:1878-1889. [PMID: 32787756 DOI: 10.2174/1381612826666200813133557] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 06/23/2020] [Indexed: 11/22/2022]
Abstract
The idea that performing a proper succession of imaging tests and techniques allows an accurate and early diagnosis of cardiac amyloidosis, avoiding the need to perform the myocardial biopsy, is becoming increasingly popular. Furthermore, being imaging techniques non-invasive, it is possible to perform the follow-up of the pathology through repeated image acquisitions. In the present review, the various innovative imaging methodologies are presented, and it is discussed how they have been applied for early diagnosis of cardiac amyloidosis (CA), also to distinguish the two most frequent subtypes in CA: immunoglobulin light chain amyloidosis (AL) and transthyretin amyloidosis (ATTR); this allows to perform the therapy in a targeted and rapid manner.
Collapse
Affiliation(s)
| | - M Scipioni
- CNR Institute of Clinical Physiology, Pisa, Italy
| | - D Genovesi
- Fondazione Toscana "G. Monasterio", Pisa, Italy
| | - A Giorgetti
- Fondazione Toscana "G. Monasterio", Pisa, Italy
| | - P Marzullo
- Fondazione Toscana "G. Monasterio", Pisa, Italy
| | - L Landini
- Fondazione Toscana "G. Monasterio", Pisa, Italy
| |
Collapse
|
21
|
Cardiac Amyloidosis: Diagnostic Tools for a Challenging Disease. CARDIOGENETICS 2021. [DOI: 10.3390/cardiogenetics11030012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Amyloidosis is a group of diseases in which amyloid fibrils build up in tissues, leading to organ dysfunction. Cardiac involvement is observed in immunoglobulin light chain amyloidosis (AL) and transthyretin amyloidosis (ATTR) and, when it occurs, the prognosis worsens. Cardiac tissue infiltration can lead to restrictive cardiomyopathy with clinical signs of diastolic heart failure, without reduction of ejection fraction (HFpEF). The aim of multiple and less invasive diagnostic tests is to discern peculiar characteristics and reach the diagnosis without performing an invasive endomyocardial biopsy. These diagnostic tools allow early diagnosis, and they are crucial to best benefit from target therapy. In this review article, we describe the mechanism behind amyloid fibril formation, infiltration of tissues, and consequent clinical signs, focusing on the diagnostic tools and the red flags to obtain a diagnosis.
Collapse
|
22
|
Dorbala S, Ando Y, Bokhari S, Dispenzieri A, Falk RH, Ferrari VA, Fontana M, Gheysens O, Gillmore JD, Glaudemans AWJM, Hanna MA, Hazenberg BPC, Kristen AV, Kwong RY, Maurer MS, Merlini G, Miller EJ, Moon JC, Murthy VL, Quarta CC, Rapezzi C, Ruberg FL, Shah SJ, Slart RHJA, Verberne HJ, Bourque JM. ASNC/AHA/ASE/EANM/HFSA/ISA/SCMR/SNMMI Expert Consensus Recommendations for Multimodality Imaging in Cardiac Amyloidosis: Part 1 of 2-Evidence Base and Standardized Methods of Imaging. Circ Cardiovasc Imaging 2021; 14:e000029. [PMID: 34196223 DOI: 10.1161/hci.0000000000000029] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Affiliation(s)
- Sharmila Dorbala
- Cardiac Amyloidosis Program, Cardiovascular Imaging Program, Departments of Radiology and Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Japan
| | - Sabahat Bokhari
- Columbia University Medical Center/New York Presbyterian Hospital, Columbia University, NY
| | - Angela Dispenzieri
- Division of Hematology, Division of Cardiovascular Diseases, and Department of Radiology, Division of Nuclear Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
| | - Rodney H Falk
- Cardiac Amyloidosis Program, Cardiovascular Imaging Program, Departments of Radiology and Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Victor A Ferrari
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, University College London, London, United Kingdom
| | - Olivier Gheysens
- Nuclear Medicine and Molecular Imaging, University Hospitals Leuven, Leuven, Belgium
| | - Julian D Gillmore
- National Amyloidosis Centre, Division of Medicine, University College London, London, United Kingdom
| | - Andor W J M Glaudemans
- Medical Imaging Center, Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Mazen A Hanna
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH
| | - Bouke P C Hazenberg
- Department of Rheumatology & Clinical Immunology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Arnt V Kristen
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany
| | - Raymond Y Kwong
- Cardiac Amyloidosis Program, Cardiovascular Imaging Program, Departments of Radiology and Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Mathew S Maurer
- Columbia University Medical Center/New York Presbyterian Hospital, Columbia University, NY
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, Foundation Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, Pavia, Italy
- Department of Molecular Medicine, University of Pavia, Italy
| | - Edward J Miller
- Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
| | - James C Moon
- National Amyloidosis Centre, Division of Medicine, University College London, London, United Kingdom
| | | | - C Cristina Quarta
- National Amyloidosis Centre, Division of Medicine, University College London, London, United Kingdom
| | - Claudio Rapezzi
- Cardiology Unit, Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater-University of Bologna, Bologna, Italy
| | - Frederick L Ruberg
- Amyloidosis Center and Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA
| | - Sanjiv J Shah
- Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Riemer H J A Slart
- Medical Imaging Center, Department of Nuclear Medicine and Molecular Imaging, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Hein J Verberne
- Division of Hematology, Division of Cardiovascular Diseases, and Department of Radiology, Division of Nuclear Medicine, Department of Medicine, Mayo Clinic, Rochester, MN
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany
| | - Jamieson M Bourque
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Department of Molecular Medicine, University of Pavia, Italy
| |
Collapse
|
23
|
Delaney FT, Dempsey P, Welaratne I, Buckley B, O'Sullivan D, O'Connell M. Incidental cardiac uptake in bone scintigraphy: increased importance and association with cardiac amyloidosis. BJR Case Rep 2021; 7:20200161. [PMID: 34131495 PMCID: PMC8171131 DOI: 10.1259/bjrcr.20200161] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 01/01/2021] [Accepted: 01/08/2021] [Indexed: 11/05/2022] Open
Abstract
Extraosseous radiotracer uptake during bone scintigraphy must be carefully assessed and it offers the potential to detect previously undiagnosed disease processes. A range of neoplastic, metabolic, traumatic, ischaemic and inflammatory disorders can cause soft tissue accumulation of bone avid radiopharmaceuticals. Accordingly, cardiac uptake in bone scintigraphy has a broad differential diagnosis and is commonly attributed to ischaemia/infarction related to coronary artery disease. However, there has been renewed focus on incidental cardiac uptake in recent years in light of significant developments in the diagnosis and management of cardiac amyloidosis.
Collapse
Affiliation(s)
- Francis T Delaney
- Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Philip Dempsey
- Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Ivan Welaratne
- Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Bryan Buckley
- Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Donagh O'Sullivan
- Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland
| | - Martin O'Connell
- Department of Radiology, Mater Misericordiae University Hospital, Dublin, Ireland
| |
Collapse
|
24
|
Bartolini S, Baldasseroni S, Fattirolli F, Silverii MV, Piccioli L, Perfetto F, Marchionni N, Di Mario C, Martone R, Taborchi G, Morini S, Vignini E, Cappelli F. Poor right ventricular function is associated with impaired exercise capacity and ventilatory efficiency in transthyretin cardiac amyloid patients. Intern Emerg Med 2021; 16:653-660. [PMID: 32918156 DOI: 10.1007/s11739-020-02474-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 08/08/2020] [Indexed: 01/09/2023]
Abstract
CardioPulmonary Exercise Test (CPET) is the gold standard to evaluate functional capacity in patients at high risk of heart failure (HF). Few studies with a limited number of subjects and conflicting results, analyzed the role of CPET in patients with systemic amyloidosis. Aims of our study were the assessment of the response to exercise in patients with Transthyretin amyloid (ATTR) cardiomyopathy (CA), and the correlation of clinical, biohumoral and echocardiographic parameters with CPET parameters, such as VO2 peak and VE/VCO2 slope. From February 2018 to March 2019, 72 cardiac ATTR patients were prospectively enrolled and underwent a complete clinical, biohumoral, echocardiographic and CPET assessment. All patients completed the exercise stress test protocol, without any adverse event. At CPET, they achieved a mean VO2 peak of 14 mL/Kg/min and a mean VE/VCO2 slope of 31. The blood pressure response to exercise was inadequate in 26 (36%) patients (flat in 25 and hypotensive in 1), while 49/72 patients (69%) showed an inadequate heart rate recovery. In multivariate analysis, s' tricuspidalic was the only independent predictor of VO2 peak, while in the two test models performed to avoid collinearity, both TAPSE and s' tricuspidalic were the strongest independent predictors of VE/VCO2 slope. Our data demonstrate the role of right ventricular function as an independent predictor of exercise capacity and ventilatory efficiency in ATTR. In CPET evaluation, a significant proportion of patients presented an abnormal arterial pressure response and heart rate variation to exercise.
Collapse
Affiliation(s)
- Simone Bartolini
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
- Cardiology Department, Azienda Sanitaria Firenze (ASF), Florence, Italy
| | | | - Francesco Fattirolli
- Cardiac Rehabilitation Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Maria Vittoria Silverii
- Cardiac Rehabilitation Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Lucrezia Piccioli
- Cardiac Rehabilitation Unit, Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Federico Perfetto
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Niccolò Marchionni
- Department of Experimental and Clinical Medicine, Division of General Cardiology, University of Florence, Careggi University Hospital, Florence, Italy
| | - Carlo Di Mario
- Department of Experimental and Clinical Medicine, Division of General Cardiology, University of Florence, Careggi University Hospital, Florence, Italy
- Division of Interventional Structural Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Raffaele Martone
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Giulia Taborchi
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Sofia Morini
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Elisa Vignini
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Francesco Cappelli
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy.
- Division of Interventional Structural Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy.
| |
Collapse
|
25
|
Abstract
PURPOSE OF REVIEW Cardiac amyloidosis is an underrecognized cause of heart failure. We review clinical clues to the diagnoses, a rational approach to testing, and current and emerging therapies. RECENT FINDINGS Advances in the diagnosis of amyloid cardiomyopathy include (1) use of 99mtechnetium (99mTc) bone-avid compounds which allow accurate noninvasive diagnosis of transthyretin cardiac amyloidosis (ATTR-CM) in the context of a negative monoclonal light chain screen; and (2) the use of serum and urine immunofixation electrophoresis with serum free light chains as an accurate first diagnostic step for light chain cardiac amyloidosis (AL-CM). Advances in treatment include tafamidis for ATTR-CM and immunologic therapies for AL-CM. With the advent of accurate noninvasive diagnostic modalities and effective therapies, early recognition of cardiac amyloidosis is paramount to implement a diagnostic algorithm and expeditiously institute effective therapies to minimize morbidity and mortality.
Collapse
|
26
|
Joseph V, Julien HM, Bravo PE. Radionuclide Imaging of Cardiac Amyloidosis. PET Clin 2021; 16:285-293. [PMID: 33589384 DOI: 10.1016/j.cpet.2020.12.010] [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: 10/22/2022]
Abstract
This article provides a review of the latest radiotracers for planar/single-photon emission computed tomography (SPECT) and positron emission tomography (PET)/computed tomography (CT) imaging of cardiac amyloidosis, detailing their affinity, specificity, and sensitivity for cardiac amyloidosis. There are several tracers available that have differing affinities for transthyretin (ATTR) and immunoglobulin light chain (AL), and new developments in technology have allowed for disease burden quantification. Bone scintigraphy is an excellent option for visualizing ATTR cardiac amyloidosis. Negative testing does not exclude the possibility of AL cardiac amyloidosis and absolute quantitation of amyloid burden is limited.
Collapse
Affiliation(s)
- Vladimir Joseph
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Howard M Julien
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Paco E Bravo
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Division of Nuclear Medicine and Clinical Molecular Imaging, Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA; Division of Cardiothoracic Imaging, Department of Radiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| |
Collapse
|
27
|
Oghina S, Bougouin W, Bézard M, Kharoubi M, Komajda M, Cohen-Solal A, Mebazaa A, Damy T, Bodez D. The Impact of Patients With Cardiac Amyloidosis in HFpEF Trials. JACC-HEART FAILURE 2021; 9:169-178. [PMID: 33549560 DOI: 10.1016/j.jchf.2020.12.005] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 11/23/2020] [Accepted: 12/02/2020] [Indexed: 01/13/2023]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is an increasingly diagnosed condition whose failure to respond to new drugs effective in heart failure with reduced ejection fraction is of great concern. HFpEF is an incompletely understood and markedly heterogeneous syndrome, but cardiac amyloidosis is increasingly recognized as one of its various causes. The specific hemodynamic and pathophysiological features of cardiac amyloidosis result in poor tolerance of heart failure medications and in worse outcomes compared with other causes. Until recently, patients considered for HFpEF trials were not routinely screened for cardiac amyloidosis. This review examines how real-world patients with cardiac amyloidosis met inclusion criteria for 8 major HFpEF clinical trials, including the recent PARAGON (Prospective Comparison of ARNI with ARB Global Outcomes in HF With Preserved Ejection Fraction) trial. This review discusses how the presence in the trial populations of a subset of patients with cardiac amyloidosis might contribute to explain the absence of efficacy of medications for HFpEF in trials so far. A multistep screening strategy is suggested in which patients with red flags for cardiac amyloidosis undergo both a light chain assay and technetium-labeled cardiac scintigraphy (technetium-labeled cardiac scintigraphy scan), which, when negative, rule out cardiac amyloidosis. Using this strategy would allow the testing of new medications for HFpEF in populations containing no patients with cardiac amyloidosis, thus potentially increasing the likelihood of showing therapeutic efficacy, and finally making some effective treatment available.
Collapse
Affiliation(s)
- Silvia Oghina
- French Referral Center for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, and DHU A-TVB, Henri Mondor Teaching Hospital, APHP, Creteil, France; Cardiology Department, Henri Mondor Teaching Hospital, Creteil, France.
| | - Wulfran Bougouin
- Paris Cardiovascular Research Center (PARCC), INSERM Unit 970, Paris, France; Ramsay Générale de Santé, Hôpital Privé Jacques Cartier, Massy, France
| | - Mélanie Bézard
- French Referral Center for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, and DHU A-TVB, Henri Mondor Teaching Hospital, APHP, Creteil, France; Cardiology Department, Henri Mondor Teaching Hospital, Creteil, France
| | - Mounira Kharoubi
- French Referral Center for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, and DHU A-TVB, Henri Mondor Teaching Hospital, APHP, Creteil, France; Cardiology Department, Henri Mondor Teaching Hospital, Creteil, France
| | - Michel Komajda
- Cardiology Department, Paris Saint Joseph Hospital, Paris, France
| | - Alain Cohen-Solal
- UMR-S 942, Université de Paris, Cardiology Department, Lariboisiere Saint-Louis Teaching Hospital, AP-HP, Paris, France
| | - Alexandre Mebazaa
- UMR-S 942 MASCOT, Université de Paris, Department of Anesthesiology and Critical Care, Lariboisiere Saint-Louis Teaching Hospital, AP-HP, Paris, France
| | - Thibaud Damy
- French Referral Center for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, and DHU A-TVB, Henri Mondor Teaching Hospital, APHP, Creteil, France; Cardiology Department, Henri Mondor Teaching Hospital, Creteil, France; Paris XII University, UPEC, and IMRB-INSERM U955, Creteil, France
| | - Diane Bodez
- French Referral Center for Cardiac Amyloidosis, GRC Amyloid Research Institute, Amyloidosis Mondor Network, and DHU A-TVB, Henri Mondor Teaching Hospital, APHP, Creteil, France; Cardiology Department, Henri Mondor Teaching Hospital, Creteil, France; Paris XII University, UPEC, and IMRB-INSERM U955, Creteil, France; Cardiology Outpatients Unit, Centre Cardiologique du Nord, Saint Denis, France
| |
Collapse
|
28
|
Gallini C, Tutino F, Martone R, Ciaccio A, Costanzo EN, Taborchi G, Morini S, Bartolini S, Farsetti S, Di Mario C, Perfetto F, Cappelli F. Semi-quantitative indices of cardiac uptake in patients with suspected cardiac amyloidosis undergoing 99mTc-HMDP scintigraphy. J Nucl Cardiol 2021; 28:90-99. [PMID: 30767162 DOI: 10.1007/s12350-019-01643-w] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Accepted: 01/11/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND 99mTc-HMDP scintigraphy has proved its efficacy in non-invasive diagnosis of cardiac amyloidosis (CA) and is currently interpreted according to the Perugini qualitative assessment. Several semi-quantitative indices have been proposed to overcome inherent possible limitations of visual grading. Our aim was to comparatively evaluate six different indices and their diagnostic performance. METHODS We retrospectively reviewed scintigraphy of 76 patients (53 ATTR, 12 AL, 11 LVH) who underwent diagnostic evaluation at our centre. ROC-curve analysis was performed to identify optimal cut-off and relative diagnostic accuracy of six different indices (of which one was proposed for the first time), both in identifying CA patients and in discriminating patients according to their Perugini score. RESULTS Heart/Whole-body ratios proved to be the most accurate (100%) in identifying CA patients. Heart/Pelvis ratio (with soft tissue background correction) offered acceptable accuracy (98%), with the largest area under the curve (AUC) (0.98) in discriminating patients with Perugini ≥ 2. Heart/Contralateral Lung ratio confirmed to be exposed to confounding background noise in case of simultaneous lung uptake. Heart/Skull ratio had the worst performance, with six false-negative patients in ATTR identification. CONCLUSION Heart/Whole-body ratios may be robust and effective semi-quantitative indices for the evaluation of CA by means of scintigraphy.
Collapse
Affiliation(s)
- Chiara Gallini
- Nuclear Medicine Unit, Careggi University Hospital, Florence, Italy
| | - Francesca Tutino
- Nuclear Medicine Unit, Careggi University Hospital, Florence, Italy
| | - Raffaele Martone
- Cardiovascular and Thoracic Department, Careggi University Hospital, Florence, Italy
| | - Alfonso Ciaccio
- Nuclear Medicine Unit, Careggi University Hospital, Florence, Italy
| | | | - Giulia Taborchi
- Cardiovascular and Thoracic Department, Careggi University Hospital, Florence, Italy
| | - Sofia Morini
- Cardiovascular and Thoracic Department, Careggi University Hospital, Florence, Italy
| | - Simone Bartolini
- Cardiovascular and Thoracic Department, Careggi University Hospital, Florence, Italy
| | - Silvia Farsetti
- Tuscan Regional Amyloid Centre, Careggi University Hospital, Florence, Italy
| | - Carlo Di Mario
- Interventional Structural Cardiology Division, Department of Heart, Lung and Vessels, Careggi University Hospital, Florence, Italy
| | - Federico Perfetto
- Tuscan Regional Amyloid Centre, Careggi University Hospital, Florence, Italy
| | - Francesco Cappelli
- Tuscan Regional Amyloid Centre, Careggi University Hospital, Florence, Italy.
- Intensive Cardiac Care Unit, Interventional Structural Cardiology Division, Department of Heart, Lung and Vessels, Careggi University Hospital, Largo Brambilla 3, 50134, Florence, Italy.
| |
Collapse
|
29
|
Small GR, Ruddy TD. Straightening out the wrinkles in technetium-99m-labeled bone scintigraphy tracer assessment of cardiac amyloidosis. J Nucl Cardiol 2021; 28:100-103. [PMID: 30977095 DOI: 10.1007/s12350-019-01718-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Accepted: 04/02/2019] [Indexed: 10/27/2022]
Affiliation(s)
- Gary R Small
- Department of Cardiac Imaging, University of Ottawa Heart Institute, Ottawa, ON, K1Y 4W7, Canada
| | - Terrence D Ruddy
- Department of Cardiac Imaging, University of Ottawa Heart Institute, Ottawa, ON, K1Y 4W7, Canada.
| |
Collapse
|
30
|
Ren C, Ren J, Tian Z, Du Y, Hao Z, Zhang Z, Fang W, Li F, Zhang S, Hsu B, Huo L. Assessment of cardiac amyloidosis with 99mTc-pyrophosphate (PYP) quantitative SPECT. EJNMMI Phys 2021; 8:3. [PMID: 33411102 PMCID: PMC7790978 DOI: 10.1186/s40658-020-00342-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 11/24/2020] [Indexed: 02/07/2023] Open
Abstract
Background 99mTc-PYP scintigraphy provides differential diagnosis of ATTR cardiomyopathy (ATTR-CM) from light chain cardiac amyloidosis and other myocardial disorders without biopsy. This study was aimed to assess the diagnostic feasibility and the operator reproducibility of 99mTc-PYP quantitative SPECT. Method Thirty-seven consecutive patients who underwent a 99mTc-PYP thorax planar scan followed by SPECT and CT scans to diagnose suspected ATTR-CM were enrolled. For the quantitative SPECT, phantom studies were initially performed to determine the image conversion factor (ICF) and partial volume correction (PVC) factor to recover 99mTc-PYP activity concentration in the myocardium for calculating the standardized uptake value (SUV) (unit: g/ml). SUVmax was compared among groups of ATTR-CM, AL cardiac amyloidosis, and other pathogens (others) and among categories of Perugini visual scores (grades 0–3). The intra- and inter-operator reproducibility of quantitative SPECT was verified, and the corresponded repeatability coefficient (RPC) was calculated. Results The ICF was 79,327 Bq/ml to convert count rate in pixel to 99mTc activity concentration. PVC factor as a function of the measured activity concentration ratio in the myocardium and blood-pool was [y = 1.424 × (1 − exp(− 0.759 × x)) + 0.104]. SUVmax of ATTR-CM (7.50 ± 2.68) was significantly higher than those of AL (1.96 ± 0.35) and others (2.00 ± 0.74) (all p < 0.05). SUVmax of grade 3 (8.95 ± 1.89) and grade 2 (4.71 ± 0.23) were also significantly higher than those of grade 1 (1.92 ± 0.31) and grade 0 (1.59 ± 0.39) (all p < 0.05). Correlation coefficient (R2) of SUVmax reached 0.966 to 0.978 with only small systematic difference (intra = − 0.14; inter = − 0.23) between two repeated measurements. Intra- and inter-operator RPCs were 0.688 and 0.877. Conclusions 99mTc-PYP quantitative SPECT integrated with adjustable PVC factors is feasible to quantitatively and objectively assess the burden of cardiac amyloidosis for diagnosis of ATTR-CM.
Collapse
Affiliation(s)
- Chao Ren
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Jingyun Ren
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Zhuang Tian
- Department of Cardiology, Peking Union Medical College Hospital, Shuaifuyuan, Dongcheng District, Beijing, People's Republic of China
| | - Yanrong Du
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Zhixin Hao
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Zongyao Zhang
- Department of Nuclear Medicine, Fuwai Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, People's Republic of China
| | - Wei Fang
- Department of Nuclear Medicine, Fuwai Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing, People's Republic of China
| | - Fang Li
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China
| | - Shuyang Zhang
- Department of Cardiology, Peking Union Medical College Hospital, Shuaifuyuan, Dongcheng District, Beijing, People's Republic of China
| | - Bailing Hsu
- Nuclear Science and Engineering Institute, University of Missouri-Columbia, E2433 Lafferre Hall, Columbia, MO, 65211, USA.
| | - Li Huo
- Department of Nuclear Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Science & Peking Union Medical College, Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, Shuaifuyuan, Dongcheng District, Beijing, 100730, People's Republic of China.
| |
Collapse
|
31
|
Cardiac Scintigraphy With Technetium-99m-Labeled Bone-Seeking Tracers for Suspected Amyloidosis: JACC Review Topic of the Week. J Am Coll Cardiol 2021; 75:2851-2862. [PMID: 32498813 DOI: 10.1016/j.jacc.2020.04.022] [Citation(s) in RCA: 117] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2020] [Revised: 04/02/2020] [Accepted: 04/02/2020] [Indexed: 12/20/2022]
Abstract
Technetium-labeled cardiac scintigraphy (i.e., Tc-PYP scan) has been repurposed for the diagnosis of transthyretin amyloid cardiomyopathy (ATTR-CM). Validated in cohorts of patients with heart failure and echocardiographic and/or cardiac magnetic resonance imaging findings suggestive of cardiac amyloidosis, cardiac scintigraphy can confirm the diagnosis of ATTR-CM only when combined with blood and urine testing to exclude a monoclonal protein. Multisocietal guidelines support the nonbiopsy diagnosis of ATTR-CM using cardiac scintigraphy, yet emphasize its use in the appropriate clinical context and the crucial need to rule out light chain amyloid cardiomyopathy. Although increased awareness of ATTR-CM and the advent of effective therapy have led to rapid adoption of diagnostic scintigraphy, there is heterogeneity in adherence to consensus guidelines. This perspective outlines clinical scenarios wherein findings on technetium-labeled cardiac scintigraphy have been misinterpreted, reviews causes of false-negative and false-positive results, and provides strategies to avoid costly and potentially fatal misdiagnoses.
Collapse
|
32
|
Grandis M, Obici L, Luigetti M, Briani C, Benedicenti F, Bisogni G, Canepa M, Cappelli F, Danesino C, Fabrizi GM, Fenu S, Ferrandes G, Gemelli C, Manganelli F, Mazzeo A, Melchiorri L, Perfetto F, Pradotto LG, Rimessi P, Tini G, Tozza S, Trevisan L, Pareyson D, Mandich P. Recommendations for pre-symptomatic genetic testing for hereditary transthyretin amyloidosis in the era of effective therapy: a multicenter Italian consensus. Orphanet J Rare Dis 2020; 15:348. [PMID: 33317601 PMCID: PMC7734774 DOI: 10.1186/s13023-020-01633-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 11/27/2020] [Indexed: 12/13/2022] Open
Abstract
Hereditary transthyretin amyloidosis (ATTRv, v for variant) is a late-onset, autosomal dominant disease caused by progressive extracellular deposition of transthyretin amyloid fibrils, leading to organ damage and death. For other late-onset fatal diseases, as Huntington’s disease, protocols for pre-symptomatic genetic testing (PST) are available since decades. For ATTRv, limited experience has been reported to date, mostly gathered before the availability of approved therapies. We aimed at developing recommendations for a safe and feasible PST protocol in ATTRv in the era of emerging treatments, taking also into account Italian patients’ characteristics and healthcare system rules. After an initial survey on ongoing approaches to PST for ATTRv in Italy, two roundtable meetings were attended by 24 experts from 16 Italian centers involved in the diagnosis and care of this disease. Minimal requirements for PST offer and potential critical issues were highlighted. By November 2019, 457 families affected by ATTRv with 209 molecularly confirmed pre-symptomatic carriers were counted. The median age at PST was 41.3 years of age, regardless of the specific mutation. Half of the Italian centers had a multidisciplinary team, including a neurologist, an internist, a cardiologist, a medical geneticist and a psychologist, although in most cases not all the specialists were available in the same center. A variable number of visits was performed at each site. Experts agreed that PST should be offered only in the context of genetic counselling to at risk individuals aged 18 or older. Advertised commercial options for DNA testing should be avoided. The protocol should consist of several steps, including a preliminary clinical examination, a pre-test information session, an interval time, the genetic test and a post-test session with the disclosure of the test results, in the context of an experienced multidisciplinary team. Recommendations for best timing were also defined. Protocols for PST in the context of ATTRv can be refined to offer at risk individuals the best chance for early diagnosis and timely treatment start, while respecting autonomous decisions and promoting safe psychological adjustment to the genetic result.
Collapse
Affiliation(s)
- M Grandis
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI), Section of Medical Genetics, University of Genoa, c/o DIMI Viale Benedetto XV, 6, 16132, Genova, Italy.,IRCCS Policlinico San Martino, Genova, Italy
| | - L Obici
- Amyloidosis Research and Treatment Center, IRCCS Fondazione Policlinico San Matteo, Pavia, Italy
| | - M Luigetti
- UOC Neurologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - C Briani
- Department of Neuroscience, University of Padova, Padova, Italy
| | - F Benedicenti
- Medical Genetics, Azienda Sanitaria Dell'Alto Adige, Bolzano, Italy
| | - G Bisogni
- Centro Clinico Nemo Adulti-Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - M Canepa
- Cardiovascular Disease Unit, IRCCS Policlinico San Martino, Genova, and IRCCS Italian Cardiovascular Network, Department of Internal Medicine, University of Genova, Genova, Italy
| | - F Cappelli
- Tuscan Regional Amyloidosis Center, Careggi University Hospital, Firenze, Italy
| | - C Danesino
- Molecular Medicine Department, University of Pavia, Pavia, Italy
| | - G M Fabrizi
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Neurology, University of Verona and University Hospital GB Rossi, Verona, Italy
| | - S Fenu
- Unit of Rare Neurodegenerative and Neurometabolic Diseases, Department of Clinical Neurosciences, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - G Ferrandes
- IRCCS Policlinico San Martino, Genova, Italy
| | - C Gemelli
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI), Section of Medical Genetics, University of Genoa, c/o DIMI Viale Benedetto XV, 6, 16132, Genova, Italy.,Neuromuscular Omnicentre (NEMO)-Fondazione Serena Onlus, Arenzano, GE, Italy
| | - F Manganelli
- Department of Neuroscience, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Napoli, Italy
| | - A Mazzeo
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - L Melchiorri
- Medical Genetics Unit, Azienda Ospedaliero Universitaria Di Ferrara, Ferrara, Italy
| | - F Perfetto
- Tuscan Regional Amyloidosis Center, Careggi University Hospital, Firenze, Italy
| | - L G Pradotto
- Department of Neurosciences, University of Turin, Torino, Italy.,Division of Neurology and Neurorehabilitazion, IRCCS Istituto Auxologico Italiano, Piancavallo, VB, Italy
| | - P Rimessi
- Medical Genetics Unit, Azienda Ospedaliero Universitaria Di Ferrara, Ferrara, Italy
| | - G Tini
- Cardiovascular Disease Unit, IRCCS Policlinico San Martino, Genova, and IRCCS Italian Cardiovascular Network, Department of Internal Medicine, University of Genova, Genova, Italy
| | - S Tozza
- Department of Neuroscience, Reproductive and Odontostomatological Sciences, University of Naples "Federico II", Napoli, Italy
| | - L Trevisan
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI), Section of Medical Genetics, University of Genoa, c/o DIMI Viale Benedetto XV, 6, 16132, Genova, Italy.,IRCCS Policlinico San Martino, Genova, Italy
| | - D Pareyson
- Unit of Rare Neurodegenerative and Neurometabolic Diseases, Department of Clinical Neurosciences, Fondazione IRCCS Istituto Neurologico Carlo Besta, Milan, Italy
| | - P Mandich
- Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI), Section of Medical Genetics, University of Genoa, c/o DIMI Viale Benedetto XV, 6, 16132, Genova, Italy. .,IRCCS Policlinico San Martino, Genova, Italy.
| |
Collapse
|
33
|
Vergaro G, Aimo A, Barison A, Genovesi D, Buda G, Passino C, Emdin M. Keys to early diagnosis of cardiac amyloidosis: red flags from clinical, laboratory and imaging findings. Eur J Prev Cardiol 2020; 27:1806-1815. [DOI: 10.1177/2047487319877708] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Abstract
Cardiac involvement in systemic amyloidosis, due either to immunoglobulin light-chain or transthyretin amyloidosis, influences clinical presentation and is a strong predictor of unfavourable outcome. Until recently considered as a rare, incurable disease, cardiac amyloidosis, is still mis/underdiagnosed, although treatments effective in improving patient survival are now available for both subtypes, including chemotherapy regimens for immunoglobulin light-chain amyloidosis and tetramer stabiliser for transthyretin amyloidosis. Achieving a timely diagnosis allows initiating life-saving therapies and requires the early recognition of clinical, laboratory and imaging signs of cardiac involvement, some of them may be apparent well before the disease becomes clinically manifest. Given the systemic nature of amyloidosis, a close interaction among experts in multiple specialties is also required, including cardiologists, nephrologists, haematologists, neurologists, radiologists, nuclear medicine specialists and internists. As an increased awareness about disease presentation is required to ameliorate diagnostic performance, we aim to provide the clinician with a guide to the screening and early diagnosis of cardiac amyloidosis, and to review the clinical, biohumoral and instrumental ‘red flags’ that should raise the suspicion of cardiac amyloidosis.
Collapse
Affiliation(s)
- Giuseppe Vergaro
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Alberto Aimo
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy
| | - Andrea Barison
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | | | - Gabriele Buda
- Department of Clinical and Experimental Medicine, University of Pisa, Italy
| | - Claudio Passino
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Michele Emdin
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Italy
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| |
Collapse
|
34
|
Frantellizzi V, Cosma L, Pani A, Pontico M, Conte M, De Angelis C, De Vincentis G. Role of Nuclear Imaging in Cardiac Amyloidosis Management: Clinical Evidence and Review of Literature. Curr Med Imaging 2020; 16:957-966. [PMID: 33081658 DOI: 10.2174/1573405615666191210103452] [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: 06/28/2019] [Revised: 10/28/2019] [Accepted: 11/19/2019] [Indexed: 11/22/2022]
Abstract
Cardiac amyloidosis (CA) is an infiltrative disease characterized by the extracellular deposition of fibrils, amyloid, in the heart. The vast majority of patients with CA has one of two types between transthyretin amyloid (ATTR) and immunoglobulin light chain associated amyloid (AL), that have different prognosis and therapeutic options. CA is often underdiagnosed. The histological analysis of endomyocardial tissue is the gold standard for the diagnosis, although it has its limitations due to its invasive nature. Nuclear medicine now plays a key role in the early and accurate diagnosis of this disease, and in the ability to distinguish between the two forms. Recent several studies support the potential advantage of bone-seeking radionuclides as a screening technique for the most common types of amyloidosis, in particular ATTR form. This review presents noninvasive modalities to diagnose CA and focuses on the radionuclide imaging techniques (bone-seeking agents scintigraphy, cardiac sympathetic innervation and positron emission tomography studies) available to visualize myocardial amyloid involvement. Furthermore, we report the case of an 83-year old male with a history of prostate cancer, carcinoma of the cecum and kidney cancer, submitted to bone scan to detect bone metastasis, that revealed a myocardial uptake of 99mTC-HMPD suggestive of ATTR CA. An accurate and early diagnosis of CA able to distinguish beyween AL and ATTR CA combined to the improving therapies could improve the survival of patients with this disease.
Collapse
Affiliation(s)
- Viviana Frantellizzi
- Department of Molecular Medicine, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Laura Cosma
- Department of Radiological Sciences, Oncology and Anatomical Pathology, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Arianna Pani
- School of Clinical Pharmacology and Toxicology, University of Milan, Milan, Italy
| | - Mariano Pontico
- Program in Morphogenesis & Tissue Engineering, Department of Medico-Surgical Sciences and Biotechnologies, Sapienza University of Rome, Rome, Italy
| | - Miriam Conte
- Department of Radiological Sciences, Oncology and Anatomical Pathology, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Cristina De Angelis
- Department of Radiological Sciences, Oncology and Anatomical Pathology, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| | - Giuseppe De Vincentis
- Department of Radiological Sciences, Oncology and Anatomical Pathology, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy
| |
Collapse
|
35
|
Ramsay SC, Cuscaden C. The current status of quantitative SPECT/CT in the assessment of transthyretin cardiac amyloidosis. J Nucl Cardiol 2020; 27:1464-1468. [PMID: 31691134 DOI: 10.1007/s12350-019-01935-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Accepted: 10/07/2019] [Indexed: 01/23/2023]
Abstract
Nuclear medicine bone scans differentiate ATTR cardiomyopathy (ATTR-CM) from light chain cardiac amyloidosis and other myocardial disorders, helping to make the diagnosis without biopsy. Standard bone scans are not absolutely quantitative, so are assessed by comparing the heart to other tissues. The standard visual scoring system compares heart to bone. This accurately diagnoses ATTR-CM and has been validated in a multicenter study, but has limitations. Semiquantitative techniques including heart/contralateral thorax (H/CL) and heart/whole body ratio (H/WB) improve on visual scoring but still rely on extracardiac sites as comparators. Absolute quantitation of myocardial uptake using quantitative SPECT should help overcome these shortcomings. In ATTR-CM, this technique is practical, accurately makes the diagnosis and provides information that is not identical to visual scores. However, more work needs to be done. The reproducibility in ATTR-CM must be tested. Larger studies need to be undertaken to determine whether quantitative SPECT measurements can assess prognosis, disease progression or treatment response. As ATTR-CM is relatively uncommon multicenter trials will help recruit enough subjects to answer these questions. Accurate measurement techniques are needed in ATTR-CM to enable appropriate use of proven therapy and to conduct trials of new therapeutic agents. Quantitative bone scans offer a promising avenue.
Collapse
Affiliation(s)
- Stuart C Ramsay
- Nuclear Medicine and PET, Royal Brisbane and Women's Hospital, Herston, QLD, Australia.
- School of Medicine, James Cook University, Townsville, Australia.
| | - Claire Cuscaden
- Department of Medical Imaging, Princess Alexandra Hospital, Wooloongabba, QLD, Australia
- The University of Queensland, St Lucia, QLD, Australia
| |
Collapse
|
36
|
Advanced Nuclear Medicine and Molecular Imaging in the Diagnosis of Cardiomyopathy. AJR Am J Roentgenol 2020; 215:1208-1217. [PMID: 32901569 DOI: 10.2214/ajr.20.22790] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE. The purpose of this article is to summarize the protocol, interpretation, and diagnostic performance of nuclear medicine and molecular imaging in imaging two distinctive, underdiagnosed cardiomyopathies: cardiac amyloidosis and cardiac sarcoidosis. CONCLUSION. Emerging new radiotracers and advanced molecular imaging modalities enable us to noninvasively characterize certain types of cardiomyopathies, including cardiac amyloidosis and cardiac sarcoidosis, with great confidence. We expect to improve recognition and promote the application of such advanced techniques in the imaging and management of these potentially lethal cardiomyopathies.
Collapse
|
37
|
Wild type transthyretin amyloidosis: Don't miss diagnosis! Int J Cardiol 2020; 312:96-97. [DOI: 10.1016/j.ijcard.2020.02.072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 02/28/2020] [Indexed: 11/23/2022]
|
38
|
Khor YM, Cuddy S, Falk RH, Dorbala S. Multimodality Imaging in the Evaluation and Management of Cardiac Amyloidosis. Semin Nucl Med 2020; 50:295-310. [PMID: 32540027 PMCID: PMC9440475 DOI: 10.1053/j.semnuclmed.2020.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Systemic amyloidosis is a heterogeneous group of disorders where misfolded proteins deposit in the various organs as nonbranching fibrils with a β-pleated-sheet structure called amyloid. Extensive extracellular deposition of these amyloid fibrils eventually leads to organ dysfunction. Involvement of the heart, termed as cardiac amyloidosis, leads to heart failure if left untreated and carries high morbidity and mortality. Current interest in cardiac amyloidosis is growing rapidly thanks to the recent development of effective targeted treatment options, driving the need for better and earlier detection of the condition, which is largely underdiagnosed and far commoner than recognized. Timely diagnosis of cardiac amyloidosis is challenging, but is poised to improve with emergence of newer noninvasive imaging techniques, potentially obviating the need for endomyocardial biopsy in some patients and providing prognostic information. With recent advances in the therapeutic options for cardiac amyloidosis, an area of immense interest is the adoption of imaging as biomarkers for longitudinal assessment of disease progression and treatment response. In this article, we provide an overview of cardiac amyloidosis, discuss the role of imaging modalities in cardiac amyloidosis, and explore future directions for imaging in cardiac amyloidosis.
Collapse
Affiliation(s)
- Yiu Ming Khor
- Department of Nuclear Medicine and Molecular Imaging, Singapore General Hospital, Singapore, Singapore
| | - Sarah Cuddy
- CV imaging program, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA
| | - Rodney H Falk
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | - Sharmila Dorbala
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA; Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, MA.
| |
Collapse
|
39
|
Lee JC, Alipour R. Hydroxymethylene diphosphonate for imaging transthyretin cardiac amyloidosis. J Nucl Cardiol 2020; 27:1040. [PMID: 30972722 DOI: 10.1007/s12350-019-01719-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 04/03/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Joseph C Lee
- Department of Medical Imaging, The Prince Charles Hospital, Chermside, QLD, 4032, Australia.
- Faculty of Medicine, University of Queensland, Brisbane, Australia.
| | - Ramin Alipour
- Department of Molecular Imaging and Therapeutic Nuclear Medicine, Cancer Imaging, Peter MacCallum Cancer Centre, Grattan St, Melbourne, VIC, 3000, Australia
| |
Collapse
|
40
|
Cappelli F, Gallini C, Perfetto F. PYP or DPD and HDP for cardiac amyloidosis one for all, all for one. J Nucl Cardiol 2020; 27:1041-1042. [PMID: 31044407 DOI: 10.1007/s12350-019-01728-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 04/10/2019] [Indexed: 11/26/2022]
Affiliation(s)
- Francesco Cappelli
- Tuscan Regional Amyloid Center, Careggi University Hospital, Florence, Italy.
- Interventional Structural Cardiology Division, Careggi University Hospital, Florence, Italy.
| | - Chiara Gallini
- Nuclear Medicine Division, Careggi University Hospital, Florence, Italy
| | - Federico Perfetto
- Tuscan Regional Amyloid Center, Careggi University Hospital, Florence, Italy
| |
Collapse
|
41
|
Low Sensitivity of Bone Scintigraphy in Detecting Phe64Leu Mutation-Related Transthyretin Cardiac Amyloidosis. JACC Cardiovasc Imaging 2020; 13:1314-1321. [DOI: 10.1016/j.jcmg.2019.10.015] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Revised: 10/07/2019] [Accepted: 10/11/2019] [Indexed: 11/29/2022]
|
42
|
Mahmarian J. A tale of two technologies: Can nuclear cardiology survive the emergence of cardiac CT the seventeenth annual Mario S. Verani lectureship. J Nucl Cardiol 2020; 27:865-890. [PMID: 32476106 DOI: 10.1007/s12350-020-02086-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Accepted: 02/19/2020] [Indexed: 11/28/2022]
Abstract
The Mario S. Verani Lectureship has traditionally been an opportunity for presenters to reflect on the state of nuclear cardiology in clinical practice and expound on new innovations in the field. Mario Verani was a visionary who embraced change and, as a cardiologist, sought to define where other cardiac imaging techniques might complement nuclear cardiology for improving patient care. Over the last decade, nuclear cardiology and cardiac computed tomography (CT) have developed in parallel with both expanding beyond the evaluation of coronary artery disease. However, many consider cardiac CT a formidable threat to nuclear cardiology due to pivotal technical innovations and its subsequent exponential growth in recent years. It is only fitting that this year's lectureship explore the relative value of both techniques in evaluating and managing cardiac disease, their relative strengths and weaknesses, and the potential value of combining nuclear cardiology and cardiac CT imaging for enhancing patient management. To Mario, my mentor, colleague for over 20 years and friend, this lectureship is truly in honor and remembrance of you.
Collapse
Affiliation(s)
- John Mahmarian
- Houston Methodist DeBakey Cardiology Associates, 6550 Fannin, Houston, TX, 77030, USA.
| |
Collapse
|
43
|
Grigoratos C, Aimo A, Rapezzi C, Genovesi D, Barison A, Aquaro GD, Vergaro G, Pucci A, Passino C, Marzullo P, Gimelli A, Emdin M. Diphosphonate single-photon emission computed tomography in cardiac transthyretin amyloidosis. Int J Cardiol 2020; 307:187-192. [PMID: 32081469 DOI: 10.1016/j.ijcard.2020.02.030] [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: 11/24/2019] [Revised: 01/26/2020] [Accepted: 02/10/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Planar diphosphonate scintigraphy is an established diagnostic tool for amyloid transthyretin (ATTR) cardiomyopathy. Characterization of the amyloid burden up to the segmental level by single photon emission computed tomography (SPECT) has not been evaluated so far. METHODS Data from consecutive patients undergoing cardiac 99mTc-hydroxymethylene diphosphonate (99mTc-HMDP) SPECT and diagnosed with ATTR cardiomyopathy at a tertiary referral center from June 2016 to April 2019 were collected. RESULTS Thirty-eight patients were included (median age 81 years, 79% men, 92% with wild-type ATTR). In patients with Perugini score 1, the most intense diphosphonate regional uptake was found in septal segments, particularly in infero-septal segments. Among patients scoring 2, the amyloid burden in the septum became more significant, and extended to inferior and apical segments. Finally, patients scoring 3 displayed an intense and widespread tracer uptake. All patients with Perugini score 1 had LGE in at least one antero-septal, one infero-septal, and one infero-lateral segment. All patients with score 2 displayed LGE in infero-septal, inferior, and infero-lateral segments. LGE became extensive in patients scoring 3, with all patients having at least one LGE-positive segment in each region. CONCLUSIONS When assimilating different Perugini grades to evolutive stages of the disease, amyloid deposition seem to progress from the septum to the inferior wall and then to the other regions and from the basis to the apex. The potential of segmental analysis might be particularly relevant in patients with very limited cardiac uptake at planar scintigraphy (Perugini score 1).
Collapse
Affiliation(s)
- Chrysanthos Grigoratos
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy; Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.
| | - Alberto Aimo
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Claudio Rapezzi
- Department of Experimental, Diagnostic, and Specialty Medicine, University of Bologna, Bologna, Italy
| | | | - Andrea Barison
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy; Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | - Giuseppe Vergaro
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy; Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | - Angela Pucci
- Histopathology Department, University Hospital of Pisa, Italy
| | - Claudio Passino
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy; Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | | | - Michele Emdin
- Fondazione Toscana Gabriele Monasterio, Pisa, Italy; Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| |
Collapse
|
44
|
Martone R, Perfetto F, Cappelli F. A Man in His 80s With Hypertension, Left Ventricular Hypertrophy, and Enlarged Biceps. JAMA Cardiol 2019; 4:1298. [DOI: 10.1001/jamacardio.2019.3899] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Raffaele Martone
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
- Tuscan Regional Amyloid Centre, Careggi University Hospital, Florence, Italy
| | - Federico Perfetto
- Tuscan Regional Amyloid Centre, Careggi University Hospital, Florence, Italy
| | - Francesco Cappelli
- Tuscan Regional Amyloid Centre, Careggi University Hospital, Florence, Italy
- Intensive Care Unit, Interventional Structural Cardiology Division, Department of Heart, Lung and Vessels, Careggi University Hospital, Florence, Italy
| |
Collapse
|
45
|
Dorbala S, Ando Y, Bokhari S, Dispenzieri A, Falk RH, Ferrari VA, Fontana M, Gheysens O, Gillmore JD, Glaudemans AWJM, Hanna MA, Hazenberg BPC, Kristen AV, Kwong RY, Maurer MS, Merlini G, Miller EJ, Moon JC, Murthy VL, Quarta CC, Rapezzi C, Ruberg FL, Shah SJ, Slart RHJA, Verberne HJ, Bourque JM. ASNC/AHA/ASE/EANM/HFSA/ISA/SCMR/SNMMI expert consensus recommendations for multimodality imaging in cardiac amyloidosis: Part 1 of 2-evidence base and standardized methods of imaging. J Nucl Cardiol 2019; 26:2065-2123. [PMID: 31468376 DOI: 10.1007/s12350-019-01760-6] [Citation(s) in RCA: 205] [Impact Index Per Article: 41.0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Sharmila Dorbala
- Cardiac Amyloidosis Program, Cardiovascular Imaging Program, Departments of Radiology and Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA.
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Sabahat Bokhari
- Columbia University Medical Center/New York Presbyterian Hospital, Columbia University, New York, NY, USA
| | - Angela Dispenzieri
- Division of Hematology, Division of Cardiovascular Diseases, and Department of Radiology, Division of Nuclear Medicine, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Rodney H Falk
- Cardiac Amyloidosis Program, Cardiovascular Imaging Program, Departments of Radiology and Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Victor A Ferrari
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Marianna Fontana
- Division of Medicine, National Amyloidosis Centre, University College London, London, UK
| | - Olivier Gheysens
- Nuclear Medicine and Molecular Imaging, University Hospitals Leuven, Leuven, Belgium
| | - Julian D Gillmore
- Division of Medicine, National Amyloidosis Centre, University College London, London, UK
| | - Andor W J M Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Mazen A Hanna
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Bouke P C Hazenberg
- Department of Rheumatology & Clinical Immunology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Arnt V Kristen
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany
| | - Raymond Y Kwong
- Cardiac Amyloidosis Program, Cardiovascular Imaging Program, Departments of Radiology and Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, MA, USA
| | - Mathew S Maurer
- Columbia University Medical Center/New York Presbyterian Hospital, Columbia University, New York, NY, USA
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, Foundation Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, Pavia, Italy
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Edward J Miller
- Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - James C Moon
- Division of Medicine, National Amyloidosis Centre, University College London, London, UK
| | | | - C Cristina Quarta
- Division of Medicine, National Amyloidosis Centre, University College London, London, UK
| | - Claudio Rapezzi
- Cardiology Unit, Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater-University of Bologna, Bologna, Italy
| | - Frederick L Ruberg
- Amyloidosis Center and Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, MA, USA
| | - Sanjiv J Shah
- Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Riemer H J A Slart
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Hein J Verberne
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jamieson M Bourque
- Departments of Medicine and Radiology, Cardiovascular Imaging Center, University of Virginia, Charlottesville, VA, USA
| |
Collapse
|
46
|
Rapezzi C, Gagliardi C, Milandri A. Analogies and disparities among scintigraphic bone tracers in the diagnosis of cardiac and non-cardiac ATTR amyloidosis. J Nucl Cardiol 2019; 26:1638-1641. [PMID: 29473120 DOI: 10.1007/s12350-018-1235-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 02/06/2018] [Indexed: 01/15/2023]
Abstract
In this issue of JNC, BW Spery and Coll report a retrospective analysis of 57 patients with transthyretin-related amyloidosis (ATTR) in an advanced phase of the disease who underwent 99mTechnetium-pyrophosphate (99mTcPYP) scintigraphy. Although relatively small and "negative," the study is relevant since it broadens our knowledge on the uptake of "bone tracers" in ATTR and contributes to understand the limitations of the clinical use of scintigraphy in this disease. The paper raises, directly or indirectly, at least three questions: To what extent are the different bone tracers interchangeable for the diagnosis of ATTR cardiac amyloidosis? Are bone tracers able to image non-cardiac ATTR amyloidosis? What is the explanation for the variable performance of the different bone tracers in the diagnosis of cardiac and extracardiac ATTR amyloidosis?
Collapse
Affiliation(s)
- Claudio Rapezzi
- Cardiology, DIMES, Alma Mater University of Bologna, Bologna, Italy.
- Policlinico S.Orsola-Malpighi, Via Massarenti 9, 40138, Bologna, Italy.
| | - Christian Gagliardi
- Cardiology, DIMES, Alma Mater University of Bologna, Bologna, Italy
- Policlinico S.Orsola-Malpighi, Via Massarenti 9, 40138, Bologna, Italy
| | - Agnese Milandri
- Cardiology, DIMES, Alma Mater University of Bologna, Bologna, Italy
- Policlinico S.Orsola-Malpighi, Via Massarenti 9, 40138, Bologna, Italy
| |
Collapse
|
47
|
Brownrigg J, Lorenzini M, Lumley M, Elliott P. Diagnostic performance of imaging investigations in detecting and differentiating cardiac amyloidosis: a systematic review and meta-analysis. ESC Heart Fail 2019; 6:1041-1051. [PMID: 31487121 PMCID: PMC6816075 DOI: 10.1002/ehf2.12511] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 07/10/2019] [Accepted: 07/30/2019] [Indexed: 12/24/2022] Open
Abstract
Aims The study aims to systematically assess the diagnostic performance of cardiac magnetic resonance (CMR) and nuclear scintigraphy (index tests) for the diagnosis and differentiation of subtypes of cardiac amyloidosis. Methods and results MEDLINE and Embase electronic databases were searched for studies evaluating the diagnostic performance of CMR or nuclear scintigraphy in detecting cardiac amyloidosis and subsequently in differentiating transthyretin amyloidosis (ATTR) from immunoglobulin light‐chain (AL) amyloidosis. In this meta‐analysis, histopathological examination of tissue from endomyocardial biopsy (EMB) or extra‐cardiac organs were reference standards. Pooled sensitivity, specificity, positive likelihood ratio, and negative likelihood ratio were calculated, and a random effects meta‐analysis was used to estimate diagnostic odds ratios. Methodological quality was assessed using a validated instrument. Of the 2947 studies identified, 27 met the criteria for inclusion. Sensitivity and specificity of CMR in diagnosing cardiac amyloidosis was 85.7% and 92.0% against EMB reference and 78.9% and 93.9% with any organ histology reference. Corresponding sensitivity and specificity of nuclear scintigraphy was 88.4% and 87.2% against EMB reference and 82.0% and 98.8% with histology from any organ. CMR was unable to reliably differentiate ATTR from AL amyloidosis (sensitivity 28.1–99.0% and specificity 11.0–60.0%). Sensitivity and specificity of nuclear scintigraphy in the differentiation of ATTR from AL amyloidosis ranged from 90.9% to 91.5% and from 88.6% to 97.1%. Pooled negative likelihood ratio and positive likelihood ratio for scintigraphy in this setting were 0.1 and 8, with EMB reference standard. Study quality assessed by QUADAS‐2 was generally poor with evidence of bias. Conclusions Cardiac magnetic resonance is a useful test for diagnosing cardiac amyloidosis but is not reliable in further classifying the disease. Nuclear scintigraphy offers strong diagnostic performance in both the detection of cardiac amyloidosis and differentiating ATTR from AL amyloidosis. Our findings support the use of both imaging modalities in a non‐invasive diagnostic algorithm that also tests for the presence of monoclonal protein.
Collapse
Affiliation(s)
- Jack Brownrigg
- Pfizer Limited, Walton Oaks, Dorking Road, Walton-on-the-Hill, Tadworth, Surrey, KT20 7NS, UK
| | | | - Matthew Lumley
- Pfizer Limited, Walton Oaks, Dorking Road, Walton-on-the-Hill, Tadworth, Surrey, KT20 7NS, UK
| | - Perry Elliott
- Barts Heart Centre, St Bartholomew's Hospital, London, UK
| |
Collapse
|
48
|
Costache II, Buburuz AM, Crisu D, Statescu AM, Ungureanu C, Aursulesei V. The role of echocardiography and 99mTc-HDP scintigraphy in non-invasive diagnosis of cardiac amyloidosis: A case series and literature review. Medicine (Baltimore) 2019; 98:e17256. [PMID: 31567998 PMCID: PMC6756609 DOI: 10.1097/md.0000000000017256] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
RATIONALE Cardiac amyloidosis, considered for the last years to be a rare disease, is one of the determinants of HFpEF. The non-specific clinical presentation and the difficulties related to endomyocardial biopsy have made cardiac amyloidosis an underdiagnosed clinical entity. Improvement of non-invasive diagnostic techniques and the development of new therapies increased clinical awareness for this form of restrictive cardiomyopathy. We here summarize echocardiography and Tc-HDP scintigraphy findings in 6 cases of cardiac amyloidosis and review the literature data of this progressive and fatal cardiomyopathy. PATIENTS CONCERNS The main clinical manifestations were fatigue, low exercise tolerance and edemas. The right heart failure symptoms usually dominated the clinical picture. DIAGNOSES All cases were evaluated by echocardiography; 3 cases were further examined by bone scintigraphy and 4 cases a peripheral biopsy was performed. Electrocardiography showed low-voltage QRS complexes and "pseudo-infarct" pattern in the precordial leads, contrary to the echocardiographic aspect, which revealed thickening of ventricle walls. Biatrial dilation and diastolic disfunction were observed. Impaired systolic function was detected in advanced stages of the disease. Tc-HDP scintigraphy revealed cardiac uptake of radiopharmaceutical and managed to confirm the diagnosis in 1 case of cardiac amyloidosis in which salivary gland biopsy was negative. INTERVENTIONS The treatment was based on managing fluid balance, with the mainstream therapy represented by diuretics. Neurohormonal agents, usually used in heart failure treatment were avoided, due to poor tolerance and worsening of disease course. The management of these 6 cases was challenging due to the refractory manifestation of congestive heart failure. OUTCOMES During follow-up, 4 of the 6 patients from the current study died in the first year after the final diagnosis was established. LESSONS Nuclear imaging of cardiac amyloidosis has a revolutionary development nowadays. Bone scintigraphy presents promising results for identifying patients at early stages of disease and to differentiate between cardiac amyloidosis types. Further studies are necessary for the standardization of imaging protocol and development of non-invasive diagnostic tools, especially in assessing the response to treatment and disease progression, for which little is known.
Collapse
Affiliation(s)
- Irina Iuliana Costache
- Department of Cardiology, “St. Spiridon” Emergency Clinical Hospital
- University of Medicine and Pharmacy “Grigore T. Popa”
| | - Ana Maria Buburuz
- Department of Cardiology, “St. Spiridon” Emergency Clinical Hospital
- University of Medicine and Pharmacy “Grigore T. Popa”
| | - Daniela Crisu
- Department of Cardiology, “St. Spiridon” Emergency Clinical Hospital
| | - Ana Maria Statescu
- Department of Nuclear Medicine, “St. Spiridon” Emergency Clinical Hospital
| | - Carmen Ungureanu
- University of Medicine and Pharmacy “Grigore T. Popa”
- Department of Pathology, “St. Spiridon” Emergency Clinical Hospital, Iasi, Romania
| | - Viviana Aursulesei
- Department of Cardiology, “St. Spiridon” Emergency Clinical Hospital
- University of Medicine and Pharmacy “Grigore T. Popa”
| |
Collapse
|
49
|
Dorbala S, Ando Y, Bokhari S, Dispenzieri A, Falk RH, Ferrari VA, Fontana M, Gheysens O, Gillmore JD, Glaudemans AWJM, Hanna MA, Hazenberg BPC, Kristen AV, Kwong RY, Maurer MS, Merlini G, Miller EJ, Moon JC, Murthy VL, Quarta CC, Rapezzi C, Ruberg FL, Shah SJ, Slart RHJA, Verberne HJ, Bourque JM. ASNC/AHA/ASE/EANM/HFSA/ISA/SCMR/SNMMI Expert Consensus Recommendations for Multimodality Imaging in Cardiac Amyloidosis: Part 1 of 2-Evidence Base and Standardized Methods of Imaging. J Card Fail 2019; 25:e1-e39. [PMID: 31473268 DOI: 10.1016/j.cardfail.2019.08.001] [Citation(s) in RCA: 89] [Impact Index Per Article: 17.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Sharmila Dorbala
- Cardiac Amyloidosis Program, Cardiovascular Imaging Program, Departments of Radiology and Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts.
| | - Yukio Ando
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Sabahat Bokhari
- Columbia University Medical Center/New York Presbyterian Hospital, Columbia University, New York, New York
| | - Angela Dispenzieri
- Division of Hematology, Division of Cardiovascular Diseases, and Department of Radiology, Division of Nuclear Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota
| | - Rodney H Falk
- Cardiac Amyloidosis Program, Cardiovascular Imaging Program, Departments of Radiology and Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Victor A Ferrari
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Marianna Fontana
- Division of Medicine, National Amyloidosis Centre, University College London, London, United Kingdom
| | - Olivier Gheysens
- Nuclear Medicine and Molecular Imaging, University Hospitals Leuven, Leuven, Belgium
| | - Julian D Gillmore
- Division of Medicine, National Amyloidosis Centre, University College London, London, United Kingdom
| | - Andor W J M Glaudemans
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Mazen A Hanna
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Bouke P C Hazenberg
- Department of Rheumatology & Clinical Immunology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Arnt V Kristen
- Department of Cardiology, University of Heidelberg, Heidelberg, Germany
| | - Raymond Y Kwong
- Cardiac Amyloidosis Program, Cardiovascular Imaging Program, Departments of Radiology and Medicine, Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Mathew S Maurer
- Columbia University Medical Center/New York Presbyterian Hospital, Columbia University, New York, New York
| | - Giampaolo Merlini
- Amyloidosis Research and Treatment Center, Foundation Istituto di Ricovero e Cura a Carattere Scientifico Policlinico San Matteo, Pavia, Italy; Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Edward J Miller
- Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - James C Moon
- Division of Medicine, National Amyloidosis Centre, University College London, London, United Kingdom
| | | | - C Cristina Quarta
- Division of Medicine, National Amyloidosis Centre, University College London, London, United Kingdom
| | - Claudio Rapezzi
- Cardiology Unit, Department of Experimental, Diagnostic and Specialty Medicine, Alma Mater-University of Bologna, Bologna, Italy
| | - Frederick L Ruberg
- Amyloidosis Center and Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts
| | - Sanjiv J Shah
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Riemer H J A Slart
- Department of Nuclear Medicine and Molecular Imaging, Medical Imaging Center, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Hein J Verberne
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jamieson M Bourque
- Departments of Medicine and Radiology, Cardiovascular Imaging Center, University of Virginia, Charlottesville, Virginia
| |
Collapse
|
50
|
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
| |
Collapse
|