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Albulushi A, Al Hajri R, Hovseth C, Jawa Z, El Hadad MG, Sallam M, Al-Mukhaini M. Advancements and challenges in cardiac amyloidosis imaging: A comprehensive review of novel techniques and clinical applications. Curr Probl Cardiol 2024; 49:102733. [PMID: 38955249 DOI: 10.1016/j.cpcardiol.2024.102733] [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: 06/25/2024] [Accepted: 06/26/2024] [Indexed: 07/04/2024]
Abstract
Cardiac amyloidosis, characterized by amyloid fibril deposition in the myocardium, leads to restrictive cardiomyopathy and heart failure. This review explores recent advancements in imaging techniques for diagnosing and managing cardiac amyloidosis, highlighting their clinical applications, strengths, and limitations. Echocardiography remains a primary, non-invasive imaging modality but lacks specificity. Cardiac MRI (CMR), with Late Gadolinium Enhancement (LGE) and T1 mapping, offers superior tissue characterization, though at higher costs and limited availability. Scintigraphy with Tc-99m-PYP reliably diagnoses transthyretin (TTR) amyloidosis but is less effective for light chain (AL) amyloidosis, necessitating complementary diagnostics. Amyloid-specific PET tracers, such as florbetapir and flutemetamol, provide precise imaging and quantitative assessment for both TTR and AL amyloidosis. Challenges include differentiating between TTR and AL amyloidosis, early disease detection, and standardizing imaging protocols. Future research should focus on developing novel tracers, integrating multimodality imaging, and leveraging AI to enhance diagnostic accuracy and personalized treatment. Advancements in imaging have improved cardiac amyloidosis management. A multimodal approach, incorporating echocardiography, CMR, scintigraphy, and PET tracers, offers comprehensive assessment. Continued innovation in tracers and AI applications promises further enhancements in diagnosis, early detection, and patient outcomes.
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Affiliation(s)
- Arif Albulushi
- Department of Adult Cardiology, National Heart Center, The Royal Hospital, Muscat, Oman.
| | - Ruqaya Al Hajri
- Department of Adult Cardiology, National Heart Center, The Royal Hospital, Muscat, Oman
| | - Chad Hovseth
- Division of Cardiovascular Medicine, Nebraska Medicine, Omaha, NE, USA
| | - Zabah Jawa
- Department of Radiology and Molecular Imaging, Sultan Qaboos University Hospital, Muscat, Oman
| | | | - Mansour Sallam
- Division of Cardiology, Armed Forces Hospital, Muscat, Oman
| | - Mohammed Al-Mukhaini
- Department of Adult Cardiology, National Heart Center, The Royal Hospital, Muscat, Oman
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Sahashi Y, Vukadinovic M, Duffy G, Li D, Cheng S, Berman DS, Ouyang D, Kwan AC. Using Deep learning to Predict Cardiovascular Magnetic Resonance Findings from Echocardiography Videos. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.04.16.24305936. [PMID: 38699330 PMCID: PMC11065018 DOI: 10.1101/2024.04.16.24305936] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/05/2024]
Abstract
Background Echocardiography is the most common modality for assessing cardiac structure and function. While cardiac magnetic resonance (CMR) imaging is less accessible, CMR can provide unique tissue characterization including late gadolinium enhancement (LGE), T1 and T2 mapping, and extracellular volume (ECV) which are associated with tissue fibrosis, infiltration, and inflammation. While deep learning has been shown to uncover findings not recognized by clinicians, it is unknown whether CMR-based tissue characteristics can be derived from echocardiography videos using deep learning. We hypothesized that deep learning applied to echocardiography could predict CMR-based measurements. Methods In a retrospective single-center study, adult patients with CMRs and echocardiography studies within 30 days were included. A video-based convolutional neural network was trained on echocardiography videos to predict CMR-derived labels including wall motion abnormality (WMA) presence, LGE presence, and abnormal T1, T2 or ECV across echocardiography views. The model performance was evaluated in a held-out test dataset not used for training. Results The study population included 1,453 adult patients (mean age 56±18 years, 42% female) with 2,556 paired echocardiography studies occurring on average 2 days after CMR (interquartile range 2 days prior to 6 days after). The model had high predictive capability for presence of WMA (AUC 0.873 [95%CI 0.816-0.922]), however, the model was unable to reliably detect the presence of LGE (AUC 0.699 [0.613-0.780]), native T1 (AUC 0.614 [0.500-0.715]), T2 0.553 [0.420-0.692], or ECV 0.564 [0.455-0.691]). Conclusions Deep learning applied to echocardiography accurately identified CMR-based WMA, but was unable to predict tissue characteristics, suggesting that signal for these tissue characteristics may not be present within ultrasound videos, and that the use of CMR for tissue characterization remains essential within cardiology. Clinical Perspective Tissue characterization of the heart muscle is useful for clinical diagnosis and prognosis by identifying myocardial fibrosis, inflammation, and infiltration, and can be measured using cardiac MRI. While echocardiography is highly accessible and provides excellent functional information, its ability to provide tissue characterization information is limited at this time. Our study using a deep learning approach to predict cardiac MRI-based tissue characteristics from echocardiography showed limited ability to do so, suggesting that alternative approaches, including non-deep learning methods should be considered in future research.
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Li Z, Yan C, Hu GX, Zhao R, Jin H, Yun H, Wei Z, Pan CZ, Shu XH, Zeng MS. Layer-specific strain in patients with cardiac amyloidosis using tissue tracking MR. FRONTIERS IN RADIOLOGY 2023; 3:1115527. [PMID: 37601532 PMCID: PMC10435886 DOI: 10.3389/fradi.2023.1115527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 07/04/2023] [Indexed: 08/22/2023]
Abstract
Background Cardiac infiltration is the major predictor of poor prognosis in patients with systemic amyloidosis, thus it becomes of great importance to evaluate cardiac involvement. Purpose We aimed to evaluate left ventricular myocardial deformation alteration in patients with cardiac amyloidosis (CA) using layer-specific tissue tracking MR. Material and Methods Thirty-nine patients with CA were enrolled. Thirty-nine normal controls were also recruited. Layer-specific tissue tracking analysis was done based on cine MR images. Results Compared with the control group, a significant reduction in LV whole layer strain values (GLS, GCS, and GRS) and layer-specific strain values was found in patients with CA (all P < 0.01). In addition, GRS and GLS, as well as subendocardial and subepicardial GLS, GRS, and GCS, were all diminished in patients with CA and reduced LVEF, when compared to those with preserved or mid-range LVEF (all P < 0.05). GCS showed the largest AUC (0.9952, P = 0.0001) with a sensitivity of 93.1% and specificity of 90% to predict reduced LVEF (<40%). Moreover, GCS was the only independent predictor of LV systolic dysfunction (Odds Ratio: 3.30, 95% CI:1.341-8.12, and P = 0.009). Conclusion Layer-specific tissue tracking MR could be a useful method to assess left ventricular myocardial deformation in patients with CA.
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Affiliation(s)
- Zheng Li
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Cardiovascular Disease, Shanghai, China
- Shanghai Institute of Medical Imaging, Shanghai, China
| | - Cheng Yan
- Shanghai Institute of Medical Imaging, Shanghai, China
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Guo-Xiang Hu
- Shanghai Institute of Medical Imaging, Shanghai, China
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Rui Zhao
- Department of Medicine, John H. Stroger, Jr. Hospital of Cook County, Chicago, IL, United States
| | - Hang Jin
- Shanghai Institute of Medical Imaging, Shanghai, China
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hong Yun
- Shanghai Institute of Medical Imaging, Shanghai, China
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zheng Wei
- Department of Hematology, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Cui-Zhen Pan
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Cardiovascular Disease, Shanghai, China
- Shanghai Institute of Medical Imaging, Shanghai, China
| | - Xian-Hong Shu
- Department of Echocardiography, Zhongshan Hospital, Fudan University, Shanghai, China
- Shanghai Institute of Cardiovascular Disease, Shanghai, China
- Shanghai Institute of Medical Imaging, Shanghai, China
| | - Meng-Su Zeng
- Shanghai Institute of Medical Imaging, Shanghai, China
- Department of Radiology, Zhongshan Hospital, Fudan University, Shanghai, China
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Impaired Extracellular Proteostasis in Patients with Heart Failure. Arch Med Res 2023; 54:211-222. [PMID: 36797157 DOI: 10.1016/j.arcmed.2023.02.001] [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: 09/11/2022] [Revised: 01/11/2023] [Accepted: 02/02/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND Proteostasis impairment and the consequent increase of amyloid burden in the myocardium have been associated with heart failure (HF) development and poor prognosis. A better knowledge of the protein aggregation process in biofluids could assist the development and monitoring of tailored interventions. AIM To compare the proteostasis status and protein's secondary structures in plasma samples of patients with HF with preserved ejection fraction (HFpEF), patients with HF with reduced ejection fraction (HFrEF), and age-matched individuals. METHODS A total of 42 participants were enrolled in 3 groups: 14 patients with HFpEF, 14 patients with HFrEF, and 14 age-matched individuals. Proteostasis-related markers were analyzed by immunoblotting techniques. Fourier Transform Infrared (FTIR) Spectroscopy in Attenuated Total Reflectance (ATR) was applied to assess changes in the protein's conformational profile. RESULTS Patients with HFrEF showed an elevated concentration of oligomeric proteic species and reduced clusterin levels. ATR-FTIR spectroscopy coupled with multivariate analysis allowed the discrimination of HF patients from age-matched individuals in the protein amide I absorption region (1700-1600 cm-1), reflecting changes in protein conformation, with a sensitivity of 73 and a specificity of 81%. Further analysis of FTIR spectra showed significantly reduced random coils levels in both HF phenotypes. Also, compared to the age-matched group, the levels of structures related to fibril formation were significantly increased in patients with HFrEF, whereas the β-turns were significantly increased in patients with HFpEF. CONCLUSION Both HF phenotypes showed a compromised extracellular proteostasis and different protein conformational changes, suggesting a less efficient protein quality control system.
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Huang H, He H, Qin Y, Du J, Song J. Independent prognostic value of left ventricular mass index in patients with light-chain amyloidosis. Acta Cardiol 2022; 77:815-821. [PMID: 36196999 DOI: 10.1080/00015385.2022.2118414] [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: 01/13/2023]
Abstract
BACKGROUND Echocardiographic-determined left ventricular mass index (LVMI) provides quantitative information on left-ventricular structure. However, its prognostic value on light-chain (AL) amyloidosis has not been clearly defined. METHODS We included 99 patients with newly diagnosed AL amyloidosis between July 2013 and March 2022. Clinical features and echocardiographic parameters were collected. RESULTS LVMI ≥113.4 g/m2 was predictive for overall survival (OS) and progression-free survival (PFS) with respective hazard ratios (HRs) of 2.87 (95% CI: 1.04-7.79) and 2.91 (95% CI: 1.25-6.68). Patients in the LVMI-high group had higher NT-proBNP, cTnT, and FLC-diff levels. They were more likely to be cardiac involved and have increased mean left ventricular wall thickness, decreased left ventricular ejection fraction, and higher proportion of patients with pericardial effusion. In subgroup analysis, LVMI-high group was associated with a reduced OS [HR: 4.74 (95% CI: 1.26-17.77)] and PFS [HR: 7.16 (95% CI: 2.10-24.40)] in patients with cardiac amyloidosis (CA). Besides, LVMI-high was associated with a reduced OS [HR: 3.58 (95% CI: 1.17-11.02)] and PFS [HR: 4.79 (95% CI: 1.77-12.94), p = 0.00] among patients staged of II or III (Mayo 2004), as well as reduced OS [HR: 22.65 (95% CI: 1.66-299.31)] and PFS [HR: 18.73 (95% CI: 2.36-148.35)] among patients staged of III or IV (Mayo 2012). CONCLUSIONS LVMI is a reliable prognostic indicator of survival. A cut-off of LVMI (113.4 g/m2) was prognostic for OS and PFS. Importantly, LVMI was able to identify a subset of patients with poorer prognosis in the context of CA or in the late stages according to the biomarker staging systems.
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Affiliation(s)
- Hejing Huang
- Department of Ultrasound, Second Affiliated Hospital of Naval Medical University (Changzheng Hospital), Shanghai, China
| | - Haiyan He
- Department of Hematology, The Myeloma & Lymphoma Center, Second Affiliated Hospital of Naval Medical University (Changzheng Hospital), Shanghai, China
| | - Yingyi Qin
- Department of Health Statistics, Naval Medical University, Shanghai, China
| | - Juan Du
- Department of Hematology, The Myeloma & Lymphoma Center, Second Affiliated Hospital of Naval Medical University (Changzheng Hospital), Shanghai, China
| | - Jialin Song
- Department of Ultrasound, Second Affiliated Hospital of Naval Medical University (Changzheng Hospital), Shanghai, China
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New Advanced Imaging Parameters and Biomarkers—A Step Forward in the Diagnosis and Prognosis of TTR Cardiomyopathy. J Clin Med 2022; 11:jcm11092360. [PMID: 35566485 PMCID: PMC9101617 DOI: 10.3390/jcm11092360] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 04/13/2022] [Accepted: 04/19/2022] [Indexed: 11/17/2022] Open
Abstract
Transthyretin amyloid cardiomyopathy (ATTR-CM) is an infiltrative disorder characterized by extracellular myocardial deposits of amyloid fibrils, with poor outcome, leading to heart failure and death, with significant treatment expenditure. In the era of a novel therapeutic arsenal of disease-modifying agents that target a myriad of pathophysiological mechanisms, timely and accurate diagnosis of ATTR-CM is crucial. Recent advances in therapeutic strategies shown to be most beneficial in the early stages of the disease have determined a paradigm shift in the screening, diagnostic algorithm, and risk classification of patients with ATTR-CM. The aim of this review is to explore the utility of novel specific non-invasive imaging parameters and biomarkers from screening to diagnosis, prognosis, risk stratification, and monitoring of the response to therapy. We will summarize the knowledge of the most recent advances in diagnostic, prognostic, and treatment tailoring parameters for early recognition, prediction of outcome, and better selection of therapeutic candidates in ATTR-CM. Moreover, we will provide input from different potential pathways involved in the pathophysiology of ATTR-CM, on top of the amyloid deposition, such as inflammation, endothelial dysfunction, reduced nitric oxide bioavailability, oxidative stress, and myocardial fibrosis, and their diagnostic, prognostic, and therapeutic implications.
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Korosoglou G, Giusca S, André F, Aus dem Siepen F, Nunninger P, Kristen AV, Frey N. Diagnostic Work-Up of Cardiac Amyloidosis Using Cardiovascular Imaging: Current Standards and Practical Algorithms. Vasc Health Risk Manag 2021; 17:661-673. [PMID: 34720583 PMCID: PMC8550552 DOI: 10.2147/vhrm.s295376] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/07/2021] [Indexed: 01/15/2023] Open
Abstract
Among non-ischemic cardiomyopathies, cardiac amyloidosis is one of the most common, being caused by extracellular depositions of amyloid fibrils in the myocardium. Two main forms of cardiac amyloidosis are known so far, including 1) light-chain (AL) amyloidosis caused by monoclonal production of light-chains, and 2) transthyretin (ATTR) amyloidosis, caused by dissociation of the transthyretin tetramer into monomers. Both AL and ATTR amyloidosis are progressive diseases with median survival from diagnosis of less than 6 months and 3 to 5 years, respectively, if untreated. In this regard, death occurs in most patients due to cardiac causes, mainly congestive heart failure, which can be prevented due to the presence of effective, life-saving treatment regimens. Therefore, early diagnosis of cardiac amyloidosis is crucial more than ever. However, diagnosis of cardiac amyloidosis may be challenging due to variable clinical manifestations and the perceived rarity of the disease. In this regard, clinical and laboratory reg flags are available, which may help clinicians to raise suspicion of cardiac amyloidosis. In addition, advances in cardiovascular imaging have already revealed a higher prevalence of cardiac amyloidosis in specific populations, so that the diagnosis especially of ATTR amyloidosis has experienced a >30-fold increase during the past ten years. The goal of our review article is to summarize these findings and provide a practical approach for clinicians on how to use cardiovascular imaging techniques, such as echocardiography, cardiac magnetic resonance, bone scintigraphy and, if required, organ biopsy within predefined diagnostic algorithms for the diagnostic work-up of patients with suspected cardiac amyloidosis. In addition, two clinical cases and practical tips are provided in this context.
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Affiliation(s)
- Grigorios Korosoglou
- GRN Hospital Weinheim, Department of Cardiology, Vascular Medicine and Pneumology, Weinheim, Germany.,Cardiac Imaging Center Weinheim, Hector Foundation, Weinheim, Germany
| | - Sorin Giusca
- GRN Hospital Weinheim, Department of Cardiology, Vascular Medicine and Pneumology, Weinheim, Germany.,Cardiac Imaging Center Weinheim, Hector Foundation, Weinheim, Germany
| | - Florian André
- Department of Cardiology, Pneumology and Angiology, University Hospital Heidelberg, Heidelberg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Heidelberg, Heidelberg, Germany
| | - Fabian Aus dem Siepen
- Department of Cardiology, Pneumology and Angiology, University Hospital Heidelberg, Heidelberg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Heidelberg, Heidelberg, Germany
| | | | - Arnt V Kristen
- Department of Cardiology, Pneumology and Angiology, University Hospital Heidelberg, Heidelberg, Germany.,Cardiovascular Center Darmstadt, Darmstadt, Germany
| | - Norbert Frey
- Department of Cardiology, Pneumology and Angiology, University Hospital Heidelberg, Heidelberg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Heidelberg, Heidelberg, Germany
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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.
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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
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Hasib Sidiqi M, Gertz MA. Immunoglobulin light chain amyloidosis diagnosis and treatment algorithm 2021. Blood Cancer J 2021; 11:90. [PMID: 33993188 PMCID: PMC8124067 DOI: 10.1038/s41408-021-00483-7] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Revised: 04/11/2021] [Accepted: 04/28/2021] [Indexed: 12/29/2022] Open
Abstract
Immunoglobulin light chain amyloidosis (AL) commonly presents with nephrotic range proteinuria, heart failure with preserved ejection fraction, nondiabetic peripheral neuropathy, unexplained hepatomegaly or diarrhea, and should be considered in patients presenting with these symptoms. More importantly, patients being monitored for smoldering multiple myeloma and a monoclonal gammopathy of undetermined significance (MGUS) are at risk for developing AL amyloidosis. MGUS and myeloma patients that have atypical features, including unexplained weight loss; lower extremity edema, early satiety, and dyspnea on exertion should be considered at risk for light chain amyloidosis. Overlooking the diagnosis of light chain amyloidosis leading to therapy delay is common, and it represents an error of diagnostic consideration. Herein we provide a review of established and investigational treatments for patients with AL amyloidosis and provide algorithms for workup and management of these patients.
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Affiliation(s)
- M Hasib Sidiqi
- Haematology Department, Fiona Stanley Hospital, Perth, WA, Australia
| | - Morie A Gertz
- Division of Hematology, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.
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Lei C, Zhu X, Hsi DH, Wang J, Zuo L, Ta S, Yang Q, Xu L, Zhao X, Wang Y, Sun S, Liu L. Predictors of cardiac involvement and survival in patients with primary systemic light-chain amyloidosis: roles of the clinical, chemical, and 3-D speckle tracking echocardiography parameters. BMC Cardiovasc Disord 2021; 21:43. [PMID: 33478398 PMCID: PMC7819214 DOI: 10.1186/s12872-021-01856-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 01/06/2021] [Indexed: 02/08/2023] Open
Abstract
Background Light-chain (AL) amyloidosis is the most common type of systemic amyloidosis with poor prognosis. Currently, the predictors of cardiac involvement and prognostic staging systems are primarily based on conventional echocardiography and serological biomarkers. We used three-dimensional speckle tracking echocardiography (STE-3D) measurements of strain, hypothesizing that it could detect cardiac involvement and aid in prediction of mortality. Methods We retrospectively analysed 74 consecutive patients with biopsy-proven AL amyloidosis. Among them, 42 showed possible cardiac involvement and 32 without cardiac involvement. LV global longitudinal strain (GLS), global radial strain, global circumferential strain and global area strain (GAS) measurements were obtained. Results The GLS and GAS were considered significant predictors of cardiac involvement. The cut-off values discriminating cardiac involvement were 16.10% for GLS, 32.95% for GAS. During the median follow-up of 12.5 months (interquartile range 4–25 months), 20 (27%) patients died. For the Cox proportional model survival analysis, heart rate, cardiac troponin T, NT-proBNP levels, E/e’, GLS, and GAS were univariate predictors of death. Multivariate Cox model showed that GLS ≤ 14.78% and cardiac troponin T ≥ 0.049 mg/l levels were independent predictors of survival. Conclusions STE-3D measurements of LV myocardial mechanics could detect cardiac involvement in patients with AL amyloidosis; GLS and cardiac biomarkers can provided prognostic information for mortality prediction.
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Affiliation(s)
- Changhui Lei
- Xijing Hypertrophic Cardiomyopathy Center, Department of Ultrasound, Xijing Hospital, Xi'an, China
| | - Xiaoli Zhu
- Xijing Hypertrophic Cardiomyopathy Center, Department of Ultrasound, Xijing Hospital, Xi'an, China
| | - David H Hsi
- Department of Cardiology, Heart and Vascular Institute, Stamford Hospital, Stamford, CT, USA
| | - Jing Wang
- Xijing Hypertrophic Cardiomyopathy Center, Department of Ultrasound, Xijing Hospital, Xi'an, China
| | - Lei Zuo
- Xijing Hypertrophic Cardiomyopathy Center, Department of Ultrasound, Xijing Hospital, Xi'an, China
| | - Shengjun Ta
- Department of Ultrasound, Yan'an Hospital, Yan'an, Shannxi, China
| | - Qianli Yang
- Xijing Hypertrophic Cardiomyopathy Center, Department of Ultrasound, Xijing Hospital, Xi'an, China
| | - Lei Xu
- Xijing Hypertrophic Cardiomyopathy Center, Department of Ultrasound, Xijing Hospital, Xi'an, China
| | - Xueli Zhao
- Xijing Hypertrophic Cardiomyopathy Center, Department of Ultrasound, Xijing Hospital, Xi'an, China
| | - Yan Wang
- Department of Nephrology, XiJing Hospital, Xi'an, Shannxi, China
| | - Shiren Sun
- Department of Nephrology, XiJing Hospital, Xi'an, Shannxi, China.
| | - Liwen Liu
- Xijing Hypertrophic Cardiomyopathy Center, Department of Ultrasound, Xijing Hospital, Xi'an, China.
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11
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Bistola V, Parissis J, Foukarakis E, Valsamaki PN, Anastasakis A, Koutsis G, Efthimiadis G, Kastritis E. Practical recommendations for the diagnosis and management of transthyretin cardiac amyloidosis. Heart Fail Rev 2021; 26:861-879. [PMID: 33452596 DOI: 10.1007/s10741-020-10062-w] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/30/2020] [Indexed: 01/01/2023]
Abstract
Cardiac amyloidosis (CA) is an infiltrative restrictive cardiomyopathy caused by accumulation in the heart interstitium of amyloid fibrils formed by misfolded proteins. Most common CA types are light chain amyloidosis (AL) caused by monoclonal immunoglobulin light chains and transthyretin amyloidosis (ATTR) caused by either mutated or wild-type transthyretin aggregates. Previously considered a rare disease, CA is increasingly recognized among patients who may be misdiagnosed as undifferentiated heart failure with preserved ejection fraction (HFPEF), paradoxical low-flow/low-gradient aortic stenosis, or otherwise unexplained left ventricular hypertrophy. Progress in diagnosis has been due to the refinement of cardiac echocardiographic techniques (speckle tracking imaging) and magnetic resonance (T1 mapping) and mostly due to the advent of bone scintigraphy that has enabled noninvasive diagnosis of ATTR, limiting the need for endomyocardial biopsy. Importantly, proper management of CA starts from early recognition of suspected cases among high prevalence populations, followed by advanced diagnostic evaluation to confirm diagnosis and typing, preferentially in experienced amyloidosis centers. Differentiating ATTR from other types of amyloidosis, especially AL, is critical. Emerging targeted ATTR therapies offer the potential to improve outcomes of these patients previously treated only palliatively.
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Affiliation(s)
- Vasiliki Bistola
- Department of Cardiology, Heart Failure Unit, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - John Parissis
- Department of Cardiology, Heart Failure Unit, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Emmanouil Foukarakis
- Cardiology Department, Venizeleion General Hospital of Heraklion, Heraklion, Greece
| | - Pipitsa N Valsamaki
- Nuclear Medicine Department, "Alexandra" University General Hospital, Athens, Greece
| | - Aris Anastasakis
- Unit of Inherited and Rare Cardiovascular Diseases, Onassis Cardiac Surgery Center, Athens, Greece
| | - Georgios Koutsis
- Neurogenetics Unit, 1st Department of Neurology, National and Kapodistrian University of Athens, Eginition University Hospital, Athens, Greece
| | - Georgios Efthimiadis
- 1st Cardiology Department, AHEPA University Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Efstathios Kastritis
- Department of Clinical Therapeutics, National and Kapodistrian University of Athens, Athens, Greece.
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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.
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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.
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13
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Rigopoulos AG, Ali M, Abate E, Torky AR, Matiakis M, Mammadov M, Melnyk H, Vogt A, de Vecchis R, Bigalke B, Wohlgemuth W, Mavrogeni S, Noutsias M. Advances in the diagnosis and treatment of transthyretin amyloidosis with cardiac involvement. Heart Fail Rev 2020; 24:521-533. [PMID: 30790171 DOI: 10.1007/s10741-019-09776-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Amyloidosis is caused by extracellular deposition of insoluble abnormal fibrils constituted by misfolded proteins, which can modify tissue anatomy and hinder the function of multiple organs including the heart. Amyloidosis that can affect the heart includes mostly systemic amyloidosis (amyloid light chain, AL) and transthyretin amyloidosis (ATTR). The latter can be acquired in elderly patients (ATTRwt), or be inherited in younger individuals (ATTRm). The diagnosis is demanding given the high phenotypic heterogeneity of the disease. Therefore, "red flags," which are suggestive features giving support to diagnostic suspicion, are extremely valuable. However, the lack of broad awareness among clinicians represents a major obstacle for early diagnosis and treatment of ATTR. Furthermore, recent implementation of noninvasive diagnostic techniques has revisited the need for endomyocardial biopsy (EMB). In fact, unlike AL amyloidosis, which requires tissue confirmation and typing for diagnosis, ATTR can now be diagnosed noninvasively with the combination of bone scintigraphy and the absence of a monoclonal protein. Securing the correct diagnosis is pivotal for the newly available therapeutic options targeting both ATTRm and ATTRwt, and are directed to either stabilization of the abnormal protein or the reduction of the production of transthyretin. The purpose of this article is to review the contemporary aspects of diagnosis and management of transthyretin amyloidosis with cardiac involvement, summarizing also the recent therapeutic advances with tafamidis, patisiran, and inotersen.
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Affiliation(s)
- Angelos G Rigopoulos
- Mid-German Heart Center, Department of Internal Medicine III (KIM-III), Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany
| | - Muhammad Ali
- Mid-German Heart Center, Department of Internal Medicine III (KIM-III), Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany
| | - Elena Abate
- Mid-German Heart Center, Department of Internal Medicine III (KIM-III), Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany
| | - Abdel-Rahman Torky
- Mid-German Heart Center, Department of Internal Medicine III (KIM-III), Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany
| | - Marios Matiakis
- Mid-German Heart Center, Department of Internal Medicine III (KIM-III), Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany
| | - Mammad Mammadov
- Mid-German Heart Center, Department of Internal Medicine III (KIM-III), Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany
| | - Hannes Melnyk
- Mid-German Heart Center, Department of Internal Medicine III (KIM-III), Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany
| | - Alexander Vogt
- Mid-German Heart Center, Department of Internal Medicine III (KIM-III), Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany
| | - Renato de Vecchis
- Preventive Cardiology and Rehabilitation Unit, DSB 29, S. Gennaro dei Poveri Hospital, 80136, Naples, Italy
| | - Boris Bigalke
- Department of Cardiology, Charité - Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, D-12200, Berlin, Germany
| | - Walter Wohlgemuth
- Department of Radiology, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany
| | - Sophie Mavrogeni
- Onassis Cardiac Surgery Center, 50 Esperou Street, 175-61, Palaeo Faliro, Athens, Greece
| | - Michel Noutsias
- Mid-German Heart Center, Department of Internal Medicine III (KIM-III), Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle, Ernst-Grube-Strasse 40, D-06120, Halle (Saale), Germany.
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14
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Muhammad Khan M, Ur Rashid M, Ullah W, Hussain I, Hurairah A. Rare case of acute on chronic hepatic failure in a patient with multiple myeloma-associated amyloidosis. BMJ Case Rep 2020; 13:13/1/e231563. [PMID: 31996385 DOI: 10.1136/bcr-2019-231563] [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: 11/04/2022] Open
Abstract
Amyloidosis is the extracellular deposition of unique protein fibrils in different tissue organs. It is most commonly associated with B-cell malignancy such as multiple myeloma or Waldenstrom macroglobulinaemia. It involves the liver, heart, kidney, peripheral nerves and soft tissues. Liver however is affected, but clinically apparent disease is very rare. Hepatomegaly and mild elevation of alkaline phosphatase is the most common presentation in patients with liver involvement. Acute hepatic failure is a rare presentation with myeloma-induced amyloidosis. The diagnosis can be difficult requiring biopsy or sometimes special staining of the tissue. Management is still very challenging.
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Affiliation(s)
| | - Mamoon Ur Rashid
- Internal Medicine, AdventHealth Dade City, Dade City, Florida, USA
| | - Waqas Ullah
- Internal Medicine, Abington Jefferson Health, Abington, Pennsylvania, USA
| | - Ishtiaq Hussain
- Internal Medicine, Mardan Medical Complex, Mardan, Khyber Pakhtunkhwa, Pakistan
| | - Abu Hurairah
- Internal Medicine, AdventHealth Dade City, Dade City, Florida, USA
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15
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Fukushima K, Nakano S, Matsunari I. Cardiac Amyloidosis: Current Diagnostic Strategies Using Multimodality Imaging. ANNALS OF NUCLEAR CARDIOLOGY 2020; 6:67-73. [PMID: 37123486 PMCID: PMC10133936 DOI: 10.17996/anc.20-00130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 07/27/2020] [Accepted: 07/27/2020] [Indexed: 05/02/2023]
Abstract
Amyloidosis is a systemic disorder in which abnormal amyloid proteins deposit in body organs, leading to organ dysfunction and death. Cardiac amyloid deposition, causing a sort of restrictive cardiomyopathy and associated with increased risk of mortality. Most cases of cardiac amyloidosis are of either light chain or transthyretin type. Early and accurate diagnosis of cardiac amyloidosis may improve outcomes. However, diagnosis requires systematic approach including electrocardiography and biomarkers when encountered suspicious candidate. Diagnosis by multimodality noninvasive imaging have been substantially studied and established for differentiation from subtypes. Recent advance in the treatment of amyloidosis offers therapeutic monitoring and prognosis.
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Affiliation(s)
- Kenji Fukushima
- Department of Nuclear Medicine, Heart Center, Saitama Medical University International Medical Center, Saitama, Japan
- Department of Cardiology, Heart Center, Saitama Medical University International Medical Center, Saitama, Japan
- Reprint requests and correspondence: Kenji Fukushima, MD, PhD, Department of Nuclear Medicine, Heart Center, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 350–1298, Japan / E-mail:
| | - Shintaro Nakano
- Department of Cardiology, Heart Center, Saitama Medical University International Medical Center, Saitama, Japan
| | - Ichiro Matsunari
- Department of Nuclear Medicine, Saitama Medical University, Saitama, Japan
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16
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Seraphim A, Westwood M, Bhuva AN, Crake T, Moon JC, Menezes LJ, Lloyd G, Ghosh AK, Slater S, Oakervee H, Manisty CH. Advanced Imaging Modalities to Monitor for Cardiotoxicity. Curr Treat Options Oncol 2019; 20:73. [PMID: 31396720 PMCID: PMC6687672 DOI: 10.1007/s11864-019-0672-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Early detection and treatment of cardiotoxicity from cancer therapies is key to preventing a rise in adverse cardiovascular outcomes in cancer patients. Over-diagnosis of cardiotoxicity in this context is however equally hazardous, leading to patients receiving suboptimal cancer treatment, thereby impacting cancer outcomes. Accurate screening therefore depends on the widespread availability of sensitive and reproducible biomarkers of cardiotoxicity, which can clearly discriminate early disease. Blood biomarkers are limited in cardiovascular disease and clinicians generally still use generic screening with ejection fraction, based on historical local expertise and resources. Recently, however, there has been growing recognition that simple measurement of left ventricular ejection fraction using 2D echocardiography may not be optimal for screening: diagnostic accuracy, reproducibility and feasibility are limited. Modern cancer therapies affect many myocardial pathways: inflammatory, fibrotic, metabolic, vascular and myocyte function, meaning that multiple biomarkers may be needed to track myocardial cardiotoxicity. Advanced imaging modalities including cardiovascular magnetic resonance (CMR), computed tomography (CT) and positron emission tomography (PET) add improved sensitivity and insights into the underlying pathophysiology, as well as the ability to screen for other cardiotoxicities including coronary artery, valve and pericardial diseases resulting from cancer treatment. Delivering screening for cardiotoxicity using advanced imaging modalities will however require a significant change in current clinical pathways, with incorporation of machine learning algorithms into imaging analysis fundamental to improving efficiency and precision. In the future, we should aspire to personalized rather than generic screening, based on a patient’s individual risk factors and the pathophysiological mechanisms of the cancer treatment they are receiving. We should aspire that progress in cardiooncology is able to track progress in oncology, and to ensure that the current ‘one size fits all’ approach to screening be obsolete in the very near future.
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Affiliation(s)
- Andreas Seraphim
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK.,Institute of Cardiovascular Sciences, University College London, Chenies Mews, London, UK
| | - Mark Westwood
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK.,Department of Cardio-oncology, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK
| | - Anish N Bhuva
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK.,Institute of Cardiovascular Sciences, University College London, Chenies Mews, London, UK
| | - Tom Crake
- Department of Cardio-oncology, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK
| | - James C Moon
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK.,Institute of Cardiovascular Sciences, University College London, Chenies Mews, London, UK
| | - Leon J Menezes
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK
| | - Guy Lloyd
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK
| | - Arjun K Ghosh
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK.,Department of Cardio-oncology, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK
| | - Sarah Slater
- Department of Haematology, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK
| | - Heather Oakervee
- Department of Oncology, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK
| | - Charlotte H Manisty
- Department of Cardiovascular Imaging, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK. .,Institute of Cardiovascular Sciences, University College London, Chenies Mews, London, UK. .,Department of Cardio-oncology, Barts Heart Centre, Barts Health NHS Trust, West Smithfield, London, EC1A 7BE, UK.
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17
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Abstract
PURPOSE OF REVIEW The aim is to provide a description of the most important echocardiographic features in systemic amyloidosis. RECENT FINDINGS Amyloidosis is a heterogeneous group of multisystem disorders, characterized by an extracellular deposition of amyloid fibrils. Several imaging tests are available for the diagnosis; however, echocardiography is the cornerstone of the non-invasive imaging modality for cardiac amyloidosis. So far, little is known about the diagnosis of cardiac amyloidosis through imaging modalities. We summarized the most important echocardiographic findings in cardiac amyloidosis. Hence, we offered a systematic report of the diagnostic performance of cardiac amyloidosis using echocardiography.
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Kyriakou P, Mouselimis D, Tsarouchas A, Rigopoulos A, Bakogiannis C, Noutsias M, Vassilikos V. Diagnosis of cardiac amyloidosis: a systematic review on the role of imaging and biomarkers. BMC Cardiovasc Disord 2018; 18:221. [PMID: 30509186 PMCID: PMC6278059 DOI: 10.1186/s12872-018-0952-8] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 11/13/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Cardiac Amyloidosis (CA) pertains to the cardiac involvement of a group of diseases, in which misfolded proteins deposit in tissues and cause progressive organ damage. The vast majority of CA cases are caused by light chain amyloidosis (AL) and transthyretin amyloidosis (ATTR). The increased awareness of these diseases has led to an increment of newly diagnosed cases each year. METHODS We performed multiple searches on MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews. Several search terms were used, such as "cardiac amyloidosis", "diagnostic modalities cardiac amyloidosis" and "staging cardiac amyloidosis". Emphasis was given on original articles describing novel diagnostic and staging approaches to the disease. RESULTS Imaging techniques are indispensable to diagnosing CA. Novel ultrasonographic techniques boast high sensitivity and specificity for the disease. Nuclear imaging has repeatedly proved its worth in the diagnostic procedure, with efforts now focusing on standardization and quantification of amyloid load. Because the latter would be invaluable for any staging system, those spearheading research in magnetic resonance imaging of the disease are also trying to come up with accurate tools to quantify amyloid burden. Staging tools are currently being developed and validated for ATTR CA, in the spirit of the acclaimed Mayo Staging System for AL. CONCLUSION Cardiac involvement confers significant morbidity and mortality in all types of amyloidosis. Great effort is made to reduce the time to diagnosis, as treatment in the initial stages of the disease is tied to better prognosis. The results of these efforts are highly sensitive and specific diagnostic modalities that are also reasonably cost effective.
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Affiliation(s)
- Panagiota Kyriakou
- 3rd Cardiology Department, Ippokrateion General Hospital of Thessaloniki, Konstantinoupoleos 49, 55 642 Thessaloniki, GR Greece
| | - Dimitrios Mouselimis
- 3rd Cardiology Department, Ippokrateion General Hospital of Thessaloniki, Konstantinoupoleos 49, 55 642 Thessaloniki, GR Greece
| | - Anastasios Tsarouchas
- 3rd Cardiology Department, Ippokrateion General Hospital of Thessaloniki, Konstantinoupoleos 49, 55 642 Thessaloniki, GR Greece
| | - Angelos Rigopoulos
- Mid-German Heart Center, Department of Internal Medicine III (KIM-III), Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Strasse 40, Halle (Saale), D-06120 Germany
| | - Constantinos Bakogiannis
- 3rd Cardiology Department, Ippokrateion General Hospital of Thessaloniki, Konstantinoupoleos 49, 55 642 Thessaloniki, GR Greece
| | - Michel Noutsias
- Mid-German Heart Center, Department of Internal Medicine III (KIM-III), Division of Cardiology, Angiology and Intensive Medical Care, University Hospital Halle, Martin-Luther-University Halle-Wittenberg, Ernst-Grube-Strasse 40, Halle (Saale), D-06120 Germany
| | - Vasileios Vassilikos
- 3rd Cardiology Department, Ippokrateion General Hospital of Thessaloniki, Konstantinoupoleos 49, 55 642 Thessaloniki, GR Greece
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19
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Gertz MA. Immunoglobulin light chain amyloidosis diagnosis and treatment algorithm 2018. Blood Cancer J 2018; 8:44. [PMID: 29795248 PMCID: PMC5966459 DOI: 10.1038/s41408-018-0080-9] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2018] [Revised: 03/13/2018] [Accepted: 03/29/2018] [Indexed: 12/18/2022] Open
Abstract
Immunoglobulin light chain amyloidosis (AL) should be considered in any patient that presents to a cancer care provider with nephrotic range proteinuria, heart failure with preserved ejection fraction, non-diabetic peripheral neuropathy, unexplained hepatomegaly or diarrhea. More importantly, patients being monitored for smoldering multiple myeloma and a monoclonal gammopathy of undetermined significance (MGUS) are at risk for developing AL amyloidosis. MGUS and myeloma patients that have atypical features, including unexplained weight loss; lower extremity edema, early satiety, and dyspnea on exertion should be considered at risk for light chain amyloidosis. Overlooking the diagnosis of light chain amyloidosis leading to therapy delay is common, and it represents an error of diagnostic consideration. Algorithms will be provided on how to evaluate patients with suspected AL amyloid as well as how to manage patients referred from other medical specialties with biopsy-proven amyloid. An organized stepwise approach to the treatment of patients with light chain amyloidosis, including established and investigational therapies, will be reviewed.
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Affiliation(s)
- Morie A Gertz
- Mayo Clinic, SW Division of Hematology, 200 First Street, Rochester, MN, 55905, USA.
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20
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Abstract
The heart, like any organ in the body, is susceptible to amyloid deposition. Although more than 30 types of protein can cause amyloidosis, only two types commonly deposit in the ventricular myocardium: amyloid light chain and amyloid transthyretin. Amyloid cardiomyopathy is usually a major determinant of patient outcomes, and the diagnosis of heart involvement can be often relatively under-diagnosed, owing to nonspecific presenting symptoms and signs at a subclinical stage. The diagnosis of cardiac amyloidosis is usually performed by endomyocardial biopsy; however, the invasive nature and related high-risk complications restrict its wide use in clinical settings. Recently, with the advent of innovative techniques used for evaluating cardiac amyloidosis, noninvasive methods become increasingly important, especially in earlier diagnosis, distinguishing typing, risk prediction and response to treatment. Here, we will review recent developments in the noninvasive methods used in the assessment of cardiac amyloidosis, focused on the laboratory biomarkers and imaging modalities.
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Affiliation(s)
- Lei Zhao
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Wangfujing, Dongcheng district, Beijing, 100730, China
| | - Quan Fang
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, No. 1 Shuaifuyuan, Wangfujing, Dongcheng district, Beijing, 100730, China.
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21
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Predictors of Prognosis in Light-Chain Amyloidosis and Chronological Changes in Cardiac Morphology and Function. Am J Cardiol 2017; 120:2041-2048. [PMID: 28947306 DOI: 10.1016/j.amjcard.2017.08.024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Revised: 08/09/2017] [Accepted: 08/14/2017] [Indexed: 11/22/2022]
Abstract
Immune light-chain (AL) amyloidosis with cardiac involvement is associated with a high mortality despite improved therapeutic regimens, but there are few reports on prognostic predictors and chronological changes in cardiac morphology and function. Prognosis and its predictors were evaluated in 36 consecutive patients with cardiac AL amyloidosis. Chronological changes in cardiac morphology and function were also evaluated. The median follow-up period was 0.95 years. The median survival time and the 3-year death-free rate after diagnosis in all-cause and cardiac deaths were 0.85 and 1.06 years and 26% and 36%, respectively. Differences in the median survival time due to left ventricular (LV) wall thickness at diagnosis were not evident. Being female and diastolic wall strain (DWS), as a measure of diastolic stiffness, were independent predictors of all-cause death in the multivariable analysis. The receiver operating characteristic analysis revealed that a DWS cut-off value of 0.189 had a sensitivity of 78% and a specificity of 72% for predicting all-cause death within 1 year after diagnosis (area under the curve = 0.726). The LV size and the stroke volume decreased and DWS worsened during the short-term follow-up period in patients who died within 1 year compared with patients who were alive after 1 year. The prognosis for patients with cardiac AL amyloidosis was poor, and DWS may be a significant predictor of prognosis. Narrowing of the LV cavity and progressive diastolic dysfunction were evident in patients with a poor prognosis.
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22
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Hsu HC, Liao MF, Hsu JL, Lo AL, Kuo HC, Lyu RK, Wu VCC, Wang CW, Ro LS. Phenotypic expressions of hereditary Transthyretin Ala97Ser related Amyloidosis (ATTR) in Taiwanese. BMC Neurol 2017; 17:178. [PMID: 28882124 PMCID: PMC5590125 DOI: 10.1186/s12883-017-0957-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2017] [Accepted: 08/30/2017] [Indexed: 01/15/2023] Open
Abstract
Background The disease course and early signs specific to ATTR Ala97Ser, the most common endemic mutation in Taiwan, have not been well described. Since new medications can slow down the rate of disease progression, the early diagnosis of this heterogeneous and fatal disease becomes critical. Methods We retrospectively reviewed the characteristics of genetically confirmed ATTR Ala97Ser patients at a tertiary referral medical center. Results Eight patients from 7 different families were enrolled (61.7 ± 5.5 years). Gastrointestinal symptoms, dyspnea or chest tightness, rather than sensory symptoms, were the initial symptoms in two patients (2/7 = 29%). Body weight loss (3/7 = 43%), muscle wasting (4/7 = 57%), or dysphagia (3/7 = 43%) were the consecutive symptoms. Orthostatic symptoms including orthostatic hypotension (7/7 = 100%), dizziness (6/7 = 86%) and syncope (5/7 = 71%) tended to develop in the late phase of the disease. Autonomic dysfunction was conspicuous. Cardiographic findings included a combination of ventricular wall thickening and pericardial effusion (7/7 = 100%), a granular sparkling appearance of the ventricular myocardium (4/7 = 57%), or conduction abnormalities (5/7 = 71%). Conclusions This study broadens the recognition of the initial signs and symptoms, including cardiographic findings and longitudinal manifestations in Taiwanese individuals with ATTR Ala97Ser mutation. These manifestations should prompt doctors to perform further studies and make an early diagnosis. Electronic supplementary material The online version of this article (10.1186/s12883-017-0957-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hui-Ching Hsu
- Department of Traditional Chinese Medicine, Division of Chinese Acupuncture and Traumatology, Chang Gung Memorial Hospital Linkou Medical Center and Chang Gung University College of Medicine, No.5, Fuxing St., Guishan Dist, Taoyuan City, 333, Taiwan, Republic of China
| | - Ming-Feng Liao
- Department of Neurology, Chang Gung Memorial Hospital Linkou Medical Center and Chang Gung University College of Medicine, No.199, Tung Hwa N. Rd., Songshan Dist, Taipei City, 105, Taiwan, Republic of China
| | - Jung-Lung Hsu
- Department of Neurology, Chang Gung Memorial Hospital Linkou Medical Center and Chang Gung University College of Medicine, No.199, Tung Hwa N. Rd., Songshan Dist, Taipei City, 105, Taiwan, Republic of China
| | - Ai-Lun Lo
- Department of Neurology, Chang Gung Memorial Hospital Linkou Medical Center and Chang Gung University College of Medicine, No.199, Tung Hwa N. Rd., Songshan Dist, Taipei City, 105, Taiwan, Republic of China
| | - Hung-Chou Kuo
- Department of Neurology, Chang Gung Memorial Hospital Linkou Medical Center and Chang Gung University College of Medicine, No.199, Tung Hwa N. Rd., Songshan Dist, Taipei City, 105, Taiwan, Republic of China
| | - Rong-Kuo Lyu
- Department of Neurology, Chang Gung Memorial Hospital Linkou Medical Center and Chang Gung University College of Medicine, No.199, Tung Hwa N. Rd., Songshan Dist, Taipei City, 105, Taiwan, Republic of China
| | - Victor Chien-Chia Wu
- Department of Cardiology, Chang Gung Memorial Hospital Linkou Medical Center and Chang Gung University College of Medicine, No.5, Fuxing St., Guishan Dist, Taoyuan City, 333, Taiwan, Republic of China
| | - Chih-Wei Wang
- Department of Anatomic Pathology, Chang Gung Memorial Hospital Linkou Medical Center and Chang Gung University College of Medicine, No.5, Fuxing St., Guishan Dist, Taoyuan City, 333, Taiwan, Republic of China
| | - Long-Sun Ro
- Department of Neurology, Chang Gung Memorial Hospital Linkou Medical Center and Chang Gung University College of Medicine, No.199, Tung Hwa N. Rd., Songshan Dist, Taipei City, 105, Taiwan, Republic of China.
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D'Andrea A, Radmilovic J, Ballo P, Mele D, Agricola E, Cameli M, Rossi A, Esposito R, Novo G, Mondillo S, Montisci R, Gallina S, Bossone E, Galderisi M. Left ventricular hypertrophy or storage disease? the incremental value of speckle tracking strain bull's-eye. Echocardiography 2017; 34:746-759. [DOI: 10.1111/echo.13506] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
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24
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Silbiger JJ. Abnormalities of the Mitral Apparatus in Hypertrophic Cardiomyopathy: Echocardiographic, Pathophysiologic, and Surgical Insights. J Am Soc Echocardiogr 2016; 29:622-39. [DOI: 10.1016/j.echo.2016.03.003] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Indexed: 12/30/2022]
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