1
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Fumagalli C, Maurer MS, Fontana M, Fine N, Gillmore J, Goyal P, Nakagawa S, Musumeci B, Grogan M, Marfella R, Limongelli G, Bo M, Longhi S, Cuddy S, Masri A, Olivotto I, Perfetto F, Ungar A, Marchionni N, Cappelli F. Comprehensive Geriatric Assessment to Optimize the Management of Older Patients With Transthyretin Cardiac Amyloidosis. JACC. ADVANCES 2024; 3:101123. [PMID: 39140080 PMCID: PMC11318635 DOI: 10.1016/j.jacadv.2024.101123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 05/30/2024] [Accepted: 06/05/2024] [Indexed: 08/15/2024]
Abstract
Transthyretin cardiac amyloidosis (ATTR-CA) predominantly affects older adults with multiple chronic conditions, leading to significant physical, cognitive, and emotional challenges. New disease-modifying drugs are effective in early stages, prompting a shift toward comprehensive assessments, including functional capacity and quality of life. However, these assessments may not fully capture the complexity of older ATTR-CA patients, especially regarding frailty and mood disorders, which can influence symptom reporting. Thus, integrating comprehensive geriatric assessment tools into routine clinical practice may be crucial to detect early signs of frailty or functional impairment that could impact outcomes and mitigate futility and ageism in the decision-making process. This review highlights the importance of evaluating multimorbidity, disability, and frailty in older patients with ATTR-CA to optimize management strategies.
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Affiliation(s)
- Carlo Fumagalli
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
- Department of Advanced Medical and Surgical Sciences, University of Campania-Luigi Vanvitelli, Naples, Italy
- National Amyloidosis Centre, University College London, Royal Free Hospital, London, United Kingdom
| | - Mathew S. Maurer
- Cardiac Amyloidosis Program, Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, New York, USA
| | - Marianna Fontana
- National Amyloidosis Centre, University College London, Royal Free Hospital, London, United Kingdom
| | - Nowell Fine
- Division of Cardiology Department of Cardiac Sciences, Medicine, and Community Health Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, Calgary, Alberta, Canada
| | - Julian Gillmore
- National Amyloidosis Centre, University College London, Royal Free Hospital, London, United Kingdom
| | - Parag Goyal
- Department of Medicine, Weill Cornell Medicine, Weill Medical College of Cornell University, New York, New York, USA
| | - Shunichi Nakagawa
- Adult Palliative Care Services, Department of Medicine, Columbia University Irving Medical Center, New York, New York, USA
| | - Beatrice Musumeci
- Cardiology Department, Clinical and Molecular Medicine Department, Sapienza University of Rome, Rome, Italy
| | - Martha Grogan
- Department of Cardiovascular Medicine, Mayo Clinic College of Medicine, Rochester, Minnesota, USA
| | - Raffaele Marfella
- Department of Advanced Medical and Surgical Sciences, University of Campania-Luigi Vanvitelli, Naples, Italy
| | - Giuseppe Limongelli
- Inherited and Rare Cardiovascular Disease, Department of Translational Medical Sciences, University of Campania “Luigi Vanvitelli”, Via L. Bianchi 1 c/o Monaldi Hospital, Naples, Italy
| | - Mario Bo
- Section of Geriatrics, Department of Medical Sciences, AOU Città della Salute e della Scienza-Molinette, Turin, Italy
| | - Simone Longhi
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Sarah Cuddy
- Cardiac Amyloidosis Program, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Ahmad Masri
- Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Iacopo Olivotto
- Department of Experimental and Clinical Medicine, Careggi University Hospital, Florence, Italy
| | - Federico Perfetto
- Department of Experimental and Clinical Medicine, Careggi University Hospital, Florence, Italy
| | - Andrea Ungar
- Department of Experimental and Clinical Medicine, Careggi University Hospital, Florence, Italy
| | - Niccolò Marchionni
- Department of Experimental and Clinical Medicine, Careggi University Hospital, Florence, Italy
| | - Francesco Cappelli
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
- Department of Experimental and Clinical Medicine, Careggi University Hospital, Florence, Italy
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2
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Izumiya Y, Kubo T, Endo J, Takashio S, Minamisawa M, Hamada J, Ishii T, Abe H, Konishi H, Tsujita K. Transthyretin amyloid cardiomyopathy: Literature review and red-flag symptom clusters for each cardiology specialty. ESC Heart Fail 2024. [PMID: 39168835 DOI: 10.1002/ehf2.15016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 06/19/2024] [Accepted: 07/22/2024] [Indexed: 08/23/2024] Open
Abstract
Wild-type transthyretin amyloid cardiomyopathy (ATTRwt-CM) is a progressive and infiltrative cardiac disorder that may cause fatal consequences if left untreated. The estimated survival time from diagnosis is approximately 3-6 years. Because of the non-specificity of initial symptom manifestation and insufficient awareness among treating physicians, approximately one-third of patients with ATTRwt-CM are initially misdiagnosed with other cardiac diseases. Although heart failure (HF) is the most common initial manifestation of ATTRwt-CM, observed in nearly 70% of affected patients, patients may also present with other cardiologic symptoms, such as atrial fibrillation (AF) and aortic stenosis (AS). This non-specific and diverse nature of the initial ATTRwt-CM presentation indicates that various cardiology subspecialties are involved in patient diagnosis and management. Standard guideline-directed pharmacological treatment for HF is not recommended for patients with ATTRwt-CM because of its limited effectiveness. However, no established algorithms are available regarding HF management in this patient population. This literature review provides an overview of the red flags for ATTRwt-CM and research findings regarding HF management in this patient population. In addition to commonly recognized red flags for ATTRwt-CM (e.g., HF, AF and severe AS), published literature identified potential red flags such as coronary microvascular dysfunction. For HF management in patients with ATTRwt-CM, the use of mineralocorticoid receptor antagonists (MRAs) was reported as a well-tolerated option associated with a low discontinuation rate and reduced mortality. Although there is no concrete evidence for recommendations against sodium-glucose cotransporter 2 inhibitor (SGLT2i) administration, research supporting its use is limited to small-scale studies. Robust evidence is lacking for AF ablation, implantable cardioverter-defibrillators and cardiac resynchronization therapy. Based on the published findings and our clinical experience as Japanese ATTRwt-CM experts, red-flag symptom clusters for each cardiology specialty (HF, arrhythmia and ischaemia/structural heart disease) and a treatment scheme for HF management are presented. As this research area remains at an exploratory stage, our observations would require further discussion among experts worldwide.
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Affiliation(s)
- Yasuhiro Izumiya
- Department of Cardiovascular Medicine, Osaka Metropolitan University Graduate School of Medicine, Osaka, Japan
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Toru Kubo
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University, Kochi, Japan
| | - Jin Endo
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Seiji Takashio
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
| | - Masatoshi Minamisawa
- Department of Cardiovascular Medicine, Shinshu University School of Medicine, Matsumoto, Japan
| | | | | | | | | | - Kenichi Tsujita
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Kumamoto, Japan
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3
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Ferkh A, Geenty P, Stefani L, Emerson P, Pham J, Byth K, Boyd AC, Richards D, Taylor MS, Kwok F, Kizana E, Thomas L. Diagnostic and prognostic value of the left atrial myopathy evaluation in cardiac amyloidosis using echocardiography. ESC Heart Fail 2024. [PMID: 39129371 DOI: 10.1002/ehf2.15013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 06/11/2024] [Accepted: 07/16/2024] [Indexed: 08/13/2024] Open
Abstract
BACKGROUND Cardiac amyloidosis (CA) is an under-recognized cause of heart failure. Left atrial (LA) myopathy contributes to a worse prognosis in heart failure and is a feature of transthyretin (ATTR) and light-chain (AL) CA. LA mechanical dispersion (LA-MD) is a novel marker of intra-atrial dyssynchrony implicated in LA myopathy and the future development of atrial fibrillation (AF). AIMS This study aimed to determine the characteristics and prognostic value of LA myopathy in ATTR and AL cardiomyopathy through a comprehensive LA echocardiographic evaluation. METHODS ATTR (n = 86) and AL (n = 86) CA patients were compared with hypertensive heart disease (HHT) patients (n = 58). Transthoracic echocardiographic measurements including LA strain and LA-MD were obtained with patient follow-up for mortality. RESULTS ATTR and AL patients had a median follow-up of 66 months, with 26 mortality events. Left ventricular (LV) mass, diastolic function (average-e' and E/e'), LV global longitudinal strain, and LA volume and function (LA function index and strain) were more impaired in ATTR versus AL; these echocardiographic parameters were more impaired in both amyloid groups compared to HHT patients (P < 0.05). LA-MD was increased in ATTR versus AL [median 72.2 (inter-quartile range 55-88.9) vs. 54 (43.5-64.2), respectively, P < 0.001]. Multivariable logistic regression adjusted for age, presence of AF, LV mass, global and basal strain, and E/e' demonstrated that LA-MD was an independent determinant of ATTR CA (P = 0.014). On multivariable analysis, LA reservoir strain was independently associated with the presence of heart failure in the CA group (P < 0.001). LA minimum volume (cut-off ≥18 mL/m2) was a determinant of mortality in AL CA [Cox proportional hazard ratio (HR) 1.042 (1.003-1.082), P = 0.034 and Kaplan-Meier analysis, P = 0.016]. CONCLUSION Characterizing LA myopathy has significant diagnostic and prognostic utility in CA. ATTR patients have increased atrial dyssynchrony, which may have implications for AF development. LA reservoir strain was associated with heart failure in CA, whilst LA minimum volume was a predictor of mortality in AL CA.
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Affiliation(s)
- Aaisha Ferkh
- Westmead Clinical School, University of Sydney, Westmead, New South Wales, Australia
- Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Paul Geenty
- Westmead Clinical School, University of Sydney, Westmead, New South Wales, Australia
- Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Luke Stefani
- Westmead Clinical School, University of Sydney, Westmead, New South Wales, Australia
- Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Peter Emerson
- Westmead Clinical School, University of Sydney, Westmead, New South Wales, Australia
- Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Jennifer Pham
- Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Karen Byth
- WSLHD Research and Education Network, Westmead Hospital, Westmead, New South Wales, Australia
| | - Anita C Boyd
- Westmead Private Cardiology, Westmead, New South Wales, Australia
| | - David Richards
- Westmead Private Cardiology, Westmead, New South Wales, Australia
| | - Mark S Taylor
- Department of Clinical Immunology and Allergy, Westmead Hospital, Westmead, New South Wales, Australia
| | - Fiona Kwok
- Department of Haematology, Westmead Hospital, Westmead, New South Wales, Australia
| | - Eddy Kizana
- Westmead Clinical School, University of Sydney, Westmead, New South Wales, Australia
- Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia
- Centre for Heart Research, The Westmead Institute for Medical Research, Westmead, New South Wales, Australia
| | - Liza Thomas
- Westmead Clinical School, University of Sydney, Westmead, New South Wales, Australia
- Department of Cardiology, Westmead Hospital, Westmead, New South Wales, Australia
- South-West Clinical School, University of New South Wales, Liverpool, New South Wales, Australia
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4
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Llerena-Velastegui J, Zumbana-Podaneva K. Advances in the Diagnosis and Management of Cardiac Amyloidosis: A Literature Review. Cardiol Res 2024; 15:211-222. [PMID: 39205961 PMCID: PMC11349137 DOI: 10.14740/cr1664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2024] [Accepted: 06/10/2024] [Indexed: 09/04/2024] Open
Abstract
Cardiac amyloidosis, increasingly recognized for its significant impact on global heart health and patient survival, demands a thorough review to understand its complexity and the urgency of improved management strategies. As a cause of cardiomyopathy and heart failure, particularly in patients with aortic stenosis and atrial fibrillation, this condition also relates to higher incidences of dementia in the affected populations. The objective of this review was to integrate and discuss the latest advancements in diagnostics and therapeutics for cardiac amyloidosis, emphasizing the implications for patient prognosis. We evaluated the latest literature from major medical databases such as PubMed and Scopus, focusing on research from 2020 to 2024, to gather comprehensive insights into the current landscape of this condition. Insights from our review highlight the complex pathophysiology of cardiac amyloidosis and the diagnostic challenges it presents. We detail the effectiveness of emerging treatments, notably gene silencing therapies like patisiran and vutrisiran, which offer transformative potential by targeting the production of amyloidogenic proteins. Additionally, the stabilization therapy acoramidis shows promise in modifying disease progression and improving clinical outcomes. This review underscores the critical need for updated clinical guidelines and further research to expand access to groundbreaking therapies and enhance disease management. Advocating for continued research and policy support, we emphasize the importance of advancing diagnostic precision and treatment effectiveness, which are vital for improving patient outcomes and addressing this debilitating disease globally.
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Affiliation(s)
- Jordan Llerena-Velastegui
- Medical School, Pontifical Catholic University of Ecuador, Quito, Ecuador
- Research Center, Center for Health Research in Latin America (CISeAL), Quito, Ecuador.
| | - Kristina Zumbana-Podaneva
- Medical School, Pontifical Catholic University of Ecuador, Quito, Ecuador
- Research Center, Center for Health Research in Latin America (CISeAL), Quito, Ecuador.
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5
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Azuma M, Kato S, Sawamura S, Fukui K, Takizawa R, Nakayama N, Ito M, Hibi K, Utsunomiya D. Prevalence of cardiac amyloidosis in atrial fibrillation: a CMR study prior to catheter ablation. Heart Vessels 2024:10.1007/s00380-024-02447-w. [PMID: 39073423 DOI: 10.1007/s00380-024-02447-w] [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] [Received: 06/05/2024] [Accepted: 07/24/2024] [Indexed: 07/30/2024]
Abstract
The frequency of cardiac amyloidosis potentially present in patients with atrial fibrillation (AF) remains unclear. The purpose of this study is to determine the frequency and clinical characteristics of cardiac amyloidosis latent in AF by performing cardiac magnetic resonance imaging (MRI) in patients scheduled for AF ablation. We retrospectively analyzed 193 consecutive patients who underwent CA and cardiac MRI for atrial fibrillation. The primary endpoint of the study was the frequency of histologically confirmed cardiac amyloidosis or suspected cardiac amyloidosis [positive imaging findings on cardiac MRI strongly suspecting cardiac amyloidosis (diffuse subendocardial late gadolinium enhancement or MRI-derived extracellular volume of > 0.40)]. Among the 193 patients, 8 were confirmed or suspected cases of cardiac amyloidosis, representing a frequency of 4% (8/193 patients). Multivariate analysis identified interventricular septal thickness at end-diastole (LVSd) as an independent and significant predictor of cardiac amyloidosis (OR: 1.72, 95% CI 1.12-2.87, p = 0.020).The optimal cut-off value for IVSd was determined to be > 12.9 mm based on the Youden index. At this cut-off, the sensitivity was 75.0% (95% CI 34.9-96.8%) and the specificity was 92.3% (95% CI 87.4-95.7%), allowing for the identification of patients with definite or suspected cardiac amyloidosis. The frequency of confirmed and suspected cases of cardiac amyloidosis among patients with an IVSd > 12.9 mm was 30% (6/20 patients). In addition, prevalence of biopsy-proven cardiac amyloidosis was 10% (2/20). The prevalence of cardiac amyloidosis in atrial fibrillation patients scheduled for ablation with cardiac hypertrophy is not negligible.
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Affiliation(s)
- Mai Azuma
- Department of Cardiology, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Shingo Kato
- Department of Diagnostic Radiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan.
| | - Shungo Sawamura
- Department of Diagnostic Radiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Kazuki Fukui
- Department of Cardiology, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Ryouya Takizawa
- Department of Cardiology, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Naoki Nakayama
- Department of Cardiology, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Masanori Ito
- Department of Radiology, Kanagawa Cardiovascular and Respiratory Center, Yokohama, Japan
| | - Kiyoshi Hibi
- Department of Cardiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Daisuke Utsunomiya
- Department of Diagnostic Radiology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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6
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Monga TS, Ekong M, Patrick K, Bommana Boyena TG, Ravanam AS, Vargas S, Mavus NB, Lakshmi AP, Singh K, Vegesna RR, Abbas K. Anticoagulation in Atrial Fibrillation Associated With Cardiac Amyloidosis: A Narrative Review. Cureus 2024; 16:e61557. [PMID: 38962633 PMCID: PMC11221388 DOI: 10.7759/cureus.61557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2024] [Indexed: 07/05/2024] Open
Abstract
Cardiac amyloidosis (CA) involves the abnormal deposition and accumulation of amyloid proteins in the heart muscle. A hallmark of disease progression is declining heart function, which can lead to structural irregularities, arrhythmias, and ultimately heart failure. Atrial fibrillation (AF) is the most common arrhythmia that presents in CA patients, and this arrhythmia is significant because it can moderately increase the risk of patients developing intracardiac thrombi, thereby putting them at risk for thromboembolic events. The management of this complication entails the use of anticoagulants like vitamin K antagonists and direct oral anticoagulants to reduce the risk of thrombus formation. This article seeks to review AF in CA and the use of anticoagulation therapy for the management and reduction of thromboembolic risk. The major conclusions of this review are centered around the need for safe administration of anticoagulant therapy to CA patients, regardless of their CHA2DS2-VASc risk score. This review highlights the importance of taking a multidisciplinary or collaborative approach to CA treatment to ensure that all aspects of this multifaceted disease can be properly managed while minimizing adverse events like bleeding risk and drug-drug interactions.
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Affiliation(s)
- Tejbir S Monga
- Internal Medicine, Spartan Health Sciences University, Vieux Fort, LCA
| | - Mfonido Ekong
- Internal Medicine, St. George's University School of Medicine, True Blue, GRD
| | - Kayé Patrick
- Anesthesiology, Spanish Town Hospital, Spanish Town, JAM
| | | | | | | | | | | | - Kanwaraj Singh
- Internal Medicine, Maharishi Markandeshwar Institute of Medical Sciences and Research, Ambala, IND
| | | | - Kiran Abbas
- Community Health Sciences, Aga Khan University, Karachi, PAK
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7
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Devgun J, Ananthasubramaniam K. Editorial commentary: Is seeing really believing? The role of the 12 lead electrocardiogram in cardiac amyloidosis. Trends Cardiovasc Med 2024; 34:265-266. [PMID: 36918135 DOI: 10.1016/j.tcm.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 03/04/2023] [Indexed: 03/16/2023]
Affiliation(s)
- Jasneet Devgun
- Heart and Vascular Institute, Henry Ford Hospital, Detroit, MI, United States
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8
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Assaf A, Mekhael M, Noujaim C, Chouman N, Younes H, Kreidieh O, Marrouche N, Donnellan E. Conduction system disease in cardiac amyloidosis. Trends Cardiovasc Med 2024; 34:250-253. [PMID: 36804858 DOI: 10.1016/j.tcm.2023.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 02/06/2023] [Accepted: 02/07/2023] [Indexed: 02/18/2023]
Abstract
Cardiac amyloidosis (CA) has diverse and deleterious effects on the conductive system. Atrial fibrillation is by far the most common electrophysiological manifestation of CA and is associated with more mortality, morbidity, and hospitalizations. While AF increases the risk of thrombosis regardless of the CHA2DS2-VASc score, the risk of thromboembolism seems to be high even in CA patients without AF. AV Nodal disease is prevalent and may precede the diagnosis of CA. The incidence of ventricular arrhythmias remains disputed, and the role of implantable cardioverter defibrillator devices in CA patients is controversial. Newer therapies targeted against specific types of CA have been developed, but their effects on conductive system disease are not well studied.
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Affiliation(s)
- Ala' Assaf
- Tulane Research Innovation for Arrhythmia Discovery (TRIAD), Tulane University School of Medicine, New Orleans, LA, USA
| | - Mario Mekhael
- Tulane Research Innovation for Arrhythmia Discovery (TRIAD), Tulane University School of Medicine, New Orleans, LA, USA
| | - Charbel Noujaim
- Tulane Research Innovation for Arrhythmia Discovery (TRIAD), Tulane University School of Medicine, New Orleans, LA, USA
| | - Nour Chouman
- Tulane Research Innovation for Arrhythmia Discovery (TRIAD), Tulane University School of Medicine, New Orleans, LA, USA
| | - Hadi Younes
- Tulane Research Innovation for Arrhythmia Discovery (TRIAD), Tulane University School of Medicine, New Orleans, LA, USA
| | - Omar Kreidieh
- Tulane Research Innovation for Arrhythmia Discovery (TRIAD), Tulane University School of Medicine, New Orleans, LA, USA
| | - Nassir Marrouche
- Tulane Research Innovation for Arrhythmia Discovery (TRIAD), Tulane University School of Medicine, New Orleans, LA, USA
| | - Eoin Donnellan
- Tulane Research Innovation for Arrhythmia Discovery (TRIAD), Tulane University School of Medicine, New Orleans, LA, USA.
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9
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Martini N, Sinigiani G, De Michieli L, Mussinelli R, Perazzolo Marra M, Iliceto S, Zorzi A, Perlini S, Corrado D, Cipriani A. Electrocardiographic features and rhythm disorders in cardiac amyloidosis. Trends Cardiovasc Med 2024; 34:257-264. [PMID: 36841466 DOI: 10.1016/j.tcm.2023.02.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/16/2023] [Accepted: 02/18/2023] [Indexed: 02/27/2023]
Abstract
Cardiac amyloidosis (CA) is an infiltrative cardiomyopathy caused by extracellular deposition of amyloid fibrils, mainly derived from transthyretin, either wild-type or hereditary variants, or immunoglobulin light chains misfolding. It is characterized by an increased left ventricular (LV) mass and diastolic dysfunction, which can lead to heart failure with preserved ejection fraction and/or conduction disturbances. The diagnosis is based on invasive pathology demonstration of amyloid deposits, or non-invasive criteria using advanced cardiovascular imaging techniques. Nevertheless, 12-lead electrocardiogram (ECG) remains of crucial importance in the assessment of patients with CA, since they can manifest peculiar features such as low QRS voltages, in discordance with the LV hypertrophy, but also pseudo-infarction patterns, sinus node dysfunction, atrioventricular blocks, premature supraventricular and ventricular beats, which support the presence of a myocardial disease. Great awareness of these common ECG characteristics of CA is needed to increase diagnostic performance and improve patient's outcome. In the present review, we discuss the current role of the ECG in the diagnosis and management of CA, focusing on the most common ECG abnormalities and rhythm disorders.
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Affiliation(s)
- Nicolò Martini
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Giulio Sinigiani
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Laura De Michieli
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Roberta Mussinelli
- Amyloidosis Research and Treatment Center, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Martina Perazzolo Marra
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Sabino Iliceto
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Alessandro Zorzi
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Stefano Perlini
- Amyloidosis Research and Treatment Center, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy; Emergency Medicine, Vascular and Metabolic Disease Unit, Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Domenico Corrado
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Alberto Cipriani
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy.
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10
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Sperry BW, Sandesara UB, Kline JA. Editorial commentary: Heart rate and rhythm in cardiac amyloidosis. Trends Cardiovasc Med 2024; 34:254-256. [PMID: 36977449 DOI: 10.1016/j.tcm.2023.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 03/23/2023] [Indexed: 03/30/2023]
Affiliation(s)
- Brett W Sperry
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA; University of Missouri-Kansas City, Kansas City, MO, USA.
| | - Uttsav B Sandesara
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA; University of Missouri-Kansas City, Kansas City, MO, USA
| | - Jessica A Kline
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA; University of Missouri-Kansas City, Kansas City, MO, USA
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11
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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.
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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
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12
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Bart NK, Fatkin D, Gunton J, Hare JL, Korczyk D, Kwok F, Lam K, Russell D, Sidiqi H, Sutton T, Gibbs SDJ, Mollee P, Thomas L. 2024 Australia-New Zealand Expert Consensus Statement on Cardiac Amyloidosis. Heart Lung Circ 2024; 33:420-442. [PMID: 38570258 DOI: 10.1016/j.hlc.2023.11.027] [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: 11/09/2023] [Accepted: 11/17/2023] [Indexed: 04/05/2024]
Abstract
Over the past 5 years, early diagnosis of and new treatments for cardiac amyloidosis (CA) have emerged that hold promise for early intervention. These include non-invasive diagnostic tests and disease modifying therapies. Recently, CA has been one of the first types of cardiomyopathy to be treated with gene editing techniques. Although these therapies are not yet widely available to patients in Australia and New Zealand, this may change in the near future. Given the rapid pace with which this field is evolving, it is important to view these advances within the Australian and New Zealand context. This Consensus Statement aims to update the Australian and New Zealand general physician and cardiologist with regards to the diagnosis, investigations, and management of CA.
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Affiliation(s)
- Nicole K Bart
- Department of Cardiology, St Vincent's Hospital, Sydney; School of Clinical Medicine, Faculty of Health and Medicine, The University of New South Wales, Sydney, and The Victor Chang Cardiac Research Institute, Sydney, NSW, Australia. http://www.twitter.com/drnikkibart
| | - Diane Fatkin
- Department of Cardiology, St Vincent's Hospital, Sydney; School of Clinical Medicine, Faculty of Health and Medicine, The University of New South Wales, Sydney, and The Victor Chang Cardiac Research Institute, Sydney, NSW, Australia
| | - James Gunton
- Department of Cardiology, Flinders Medical Centre, Adelaide, SA, Australia
| | - James L Hare
- Department of Cardiology, Alfred Health, Melbourne, and Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Vic, Australia
| | - Dariusz Korczyk
- Department of Cardiology, The Princess Alexandra Hospital, Brisbane, Qld, Australia
| | - Fiona Kwok
- Department of Haematology, Westmead Hospital, Sydney, NSW, Australia
| | - Kaitlyn Lam
- Department of Cardiology, Western Australia Advanced Heart Failure and Cardiac Transplant Service, Perth, WA, Australia
| | - David Russell
- Department of Cardiology, Royal Hobart Hospital, Hobart, Tas, Australia
| | - Hasib Sidiqi
- Department of Haematology, Fiona Stanley Hospital, Perth, WA, Australia
| | - Tim Sutton
- Te Whatu Ora Counties Manukau, Auckland; and Department of Cardiology, Auckland, Aotearoa, New Zealand
| | - Simon D J Gibbs
- Department of Haematology, Eastern Health; Epworth Freemasons; and Monash University, Melbourne, Vic, Australia
| | - Peter Mollee
- Queensland Amyloidosis Centre, The Princess Alexandra Hospital, Brisbane; and, School of Medicine, University of Queensland, Brisbane, Qld, Australia
| | - Liza Thomas
- Department of Cardiology, Westmead Hospital, Sydney; Westmead Clinical School, University of Sydney, Sydney; and, South West Clinical School, University of New South Wales, Sydney, NSW, Australia.
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13
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Gallo-Fernández I, López-Aguilera J, González-Manzanares R, Pericet-Rodriguez C, Carmona-Rico MJ, Perea-Armijo J, Castillo-Domínguez JC, Anguita-Sánchez M. [Clinical differences between transthyretin cardiac amyloidosis and hypertensive heart disease]. Med Clin (Barc) 2024; 162:205-212. [PMID: 38044190 DOI: 10.1016/j.medcli.2023.10.006] [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: 05/15/2023] [Revised: 10/08/2023] [Accepted: 10/10/2023] [Indexed: 12/05/2023]
Abstract
INTRODUCTION A significant percentage of patients eventually diagnosed with cardiac transthyretin amyloidosis (TTRA) was previously diagnosed with hypertensive heart disease (HHD), since both conditions usually present with heart failure (HF) with preserved ejection fraction (HFpEF) and ventricular hypertrophy. Our objectives were to evaluate the clinical, electrocardiographic and echocardiographic differences, and to analyse whether there exists a differential prognosis between these two nosological entities. MATERIALS AND METHODS We retrospectively included all patients with HHD for whom a cardiac scintigraphy with 99mTc-diphosphonate (GDPD) and a free light chains test in blood and urine were ordered for ATTR screening in our centre, in the period between 2016 and 2021. Those diagnosed with other types of amyloidosis were excluded from the analysis. RESULTS A total of 72 patients were analyzed: 33 were finally diagnosed with TTRA and 39 with CHTA. Patients with TTRA had higher levels of ultrasensitive troponin I (TnI-US) and N-terminal brain natriuretic propeptide (NT-ProBNP); in electrocardiography (ECG) they presented a pseudo-infarction pattern more frequently as well as conduction disturbances; in echocardiography (TTE) they presented a higher degree of ventricular hypertrophy, left ventricular dysfunction and worse diastolic function parameters, with elevated filling pressures. In the 4-year follow-up, the ATTR group showed greater need for pacemaker (PCM), with no evidence regarding mortality, development of atrial fibrillation (AF), or more admissions for heart failure (HF). CONCLUSIONS In our series, patients with TTRA showed clinical, electrocardiographic and echocardiographic differences compared to patients with HHD, with increased risk of need for PCM.
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Affiliation(s)
- Ignacio Gallo-Fernández
- Unidad de Insuficiencia Cardiaca, Servicio de Cardiología, Hospital Universitario Reina Sofía, Córdoba, España; Instituto de Investigación Biomédica de Córdoba, IMIBIC, Córdoba, España
| | - José López-Aguilera
- Unidad de Insuficiencia Cardiaca, Servicio de Cardiología, Hospital Universitario Reina Sofía, Córdoba, España; Instituto de Investigación Biomédica de Córdoba, IMIBIC, Córdoba, España.
| | - Rafael González-Manzanares
- Unidad de Insuficiencia Cardiaca, Servicio de Cardiología, Hospital Universitario Reina Sofía, Córdoba, España; Instituto de Investigación Biomédica de Córdoba, IMIBIC, Córdoba, España
| | - Cristina Pericet-Rodriguez
- Unidad de Insuficiencia Cardiaca, Servicio de Cardiología, Hospital Universitario Reina Sofía, Córdoba, España; Instituto de Investigación Biomédica de Córdoba, IMIBIC, Córdoba, España
| | | | - Jorge Perea-Armijo
- Unidad de Insuficiencia Cardiaca, Servicio de Cardiología, Hospital Universitario Reina Sofía, Córdoba, España; Instituto de Investigación Biomédica de Córdoba, IMIBIC, Córdoba, España; Universidad de Córdoba, Córdoba, España
| | - Juan Carlos Castillo-Domínguez
- Unidad de Insuficiencia Cardiaca, Servicio de Cardiología, Hospital Universitario Reina Sofía, Córdoba, España; Instituto de Investigación Biomédica de Córdoba, IMIBIC, Córdoba, España
| | - Manuel Anguita-Sánchez
- Unidad de Insuficiencia Cardiaca, Servicio de Cardiología, Hospital Universitario Reina Sofía, Córdoba, España; Instituto de Investigación Biomédica de Córdoba, IMIBIC, Córdoba, España
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14
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Chen Z, Shi A, Dong H, Laptseva N, Chen F, Yang J, Guo X, Duru F, Chen K, Chen L. Prognostic implications of premature ventricular contractions and non-sustained ventricular tachycardia in light-chain cardiac amyloidosis. Europace 2024; 26:euae063. [PMID: 38466042 DOI: 10.1093/europace/euae063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 03/06/2024] [Indexed: 03/12/2024] Open
Abstract
AIMS Premature ventricular contractions (PVC) and non-sustained ventricular tachycardia (NSVT) are commonly observed in light chain cardiac amyloidosis (AL-CA), but their association with prognosis is still unclear. We aimed to evaluate the prognostic value of PVCs and NSVT in patients with moderate-to-advanced AL-CA. METHODS AND RESULTS We retrospectively included patients with AL-CA at modified 2004 Mayo stages II-IIIb between February 2014 and December 2020. Twenty-four-hour Holter recordings were assessed on admission. The outcomes included (i) new onset of adverse ventricular arrhythmia (VA) or sudden cardiac death (SCD) and (ii) cardiac death during follow-up. Of the 143 patients studied (60.41 ± 11.06 years, male 64.34%), 132 (92.31%) had presence of PVC, and 50 (34.97%) had NSVT on Holter. Twelve (8.4%) patients died in hospital and 131 patients were followed up (median 24.4 months), among whom 71 patients had cardiac death, and 15 underwent adverse VA/SCD. NSVT [hazard ratio (HR): 13.57, 95% confidence interval (CI): 3.06-60.18, P < 0.001], log-transformed PVC counts (HR: 1.46, 95%CI: 1.15-1.86, P = 0.002) and PVC burden (HR: 1.43 95%CI:1.14-1.80, P = 0.002) were predictive of new onset of adverse VA/SCD. The highest tertile of PVC counts (HR: 2.33, 95%CI: 1.27-4.28, P = 0.006) and PVC burden (HR: 2.58, 95%CI: 1.42-4.69, P = 0.002), rather than NSVT (HR: 1.16, 95%CI: 0.67-1.98, P = 0.603), was associated with cardiac death. Higher PVC counts/burden provided incremental value on modified 2004 Mayo stage in predicting cardiac death, with C index increasing from 0.681 to 0.712 and 0.717, respectively (P values <0.05). CONCLUSION PVC count, burden, and NSVT significantly correlated with adverse VA/SCD during follow-up in patients with AL-CA. Higher PVC counts/burdens added incremental value for predicting cardiac death.
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Affiliation(s)
- Zhongli Chen
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No. 167 North Lishi Road, Xicheng District, Beijing 100037, China
- Cardiac Arrhythmia Center, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No. 167 North Lishi Road, Xicheng District, Beijing 10037, China
| | - Anteng Shi
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No. 167 North Lishi Road, Xicheng District, Beijing 100037, China
| | - Hongbin Dong
- Department of Radiology, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No. 167 North Lishi Road, Xicheng District, Beijing 10037, China
| | - Natallia Laptseva
- Division of Heart Failure, Department of Cardiology, University Heart Center, Rämistrasse 100, Zurich CH-8091, Switzerland
| | - Feng Chen
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No. 167 North Lishi Road, Xicheng District, Beijing 100037, China
- Cardiac Arrhythmia Center, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No. 167 North Lishi Road, Xicheng District, Beijing 10037, China
| | - Jiandu Yang
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No. 167 North Lishi Road, Xicheng District, Beijing 100037, China
- Cardiac Arrhythmia Center, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No. 167 North Lishi Road, Xicheng District, Beijing 10037, China
| | - Xiaogang Guo
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No. 167 North Lishi Road, Xicheng District, Beijing 100037, China
- Cardiac Arrhythmia Center, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No. 167 North Lishi Road, Xicheng District, Beijing 10037, China
| | - Firat Duru
- Center for Translational and Experimental Cardiology, University of Zurich, Rämistrasse 100, Zurich CH-8091, Switzerland
- Division of Cardiac Arrhythmias, Department of Cardiology, University Heart Center, Rämistrasse 100, Zurich CH-8091, Switzerland
| | - Keping Chen
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No. 167 North Lishi Road, Xicheng District, Beijing 100037, China
- Cardiac Arrhythmia Center, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No. 167 North Lishi Road, Xicheng District, Beijing 10037, China
| | - Liang Chen
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No. 167 North Lishi Road, Xicheng District, Beijing 100037, China
- Center for Translational and Experimental Cardiology, University of Zurich, Rämistrasse 100, Zurich CH-8091, Switzerland
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15
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Sabbour H, Al-Humood K, Al Taha Z, Romany I, Haddadin H, Mohty D. A wolf in sheep's clothing-aortic stenosis and cardiac amyloidosis: "RAISE"ing awareness in clinical practice. Front Cardiovasc Med 2024; 11:1323023. [PMID: 38464842 PMCID: PMC10921426 DOI: 10.3389/fcvm.2024.1323023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 01/15/2024] [Indexed: 03/12/2024] Open
Abstract
Aesop's fable of the wolf in sheep's clothing encourages us to look beneath the exterior appearance of a situation and evaluate the truth that lies beneath. This concept should be applied when managing older patients with severe aortic stenosis. This population of patients is increasingly being identified as having concomitant cardiac amyloidosis, which is an underrecognized cause of common cardiac conditions. The presence of cardiac amyloidosis negatively affects the outcome of patients with aortic stenosis, these patients undergo transcatheter aortic valve replacement (TAVR) with increasing frequency and have a significantly higher overall mortality rate than patients with aortic stenosis alone. Although left ventricular wall hypertrophy is expected in patients with aortic stenosis, it should not be assumed that this is caused only by aortic stenosis. A suspicion of cardiac amyloidosis should be raised in patients in whom the degree of hypertrophy is disproportionate to the degree of aortic stenosis severity. The remodeling, age, injury, systemic, and electrical (RAISE) score was developed to predict the presence of cardiac amyloidosis in patients with severe aortic stenosis. This article highlights the value of increased clinical suspicion, demonstrates the use of the multiparameter RAISE score in daily clinical practice, and illustrates the scoring system with case studies. In elderly patients being considered for TAVR, systematic testing for cardiac amyloidosis should be considered as part of the preoperative workup.
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Affiliation(s)
- H. Sabbour
- Heart and Vascular Institute, Cleveland Clinic, Abu Dhabi, United Arab Emirates
- Warren Alpert School of Medicine, Brown University, Providence, RI, United States
| | - K. Al-Humood
- Advanced Heart Failure and Transplantation Unit, Chest Disease Hospital, Kuwait City, Kuwait
| | - Z. Al Taha
- Sheikh Shakhbout Medical City, Abu Dhabi, United Arab Emirates
| | - I. Romany
- Pfizer Gulf FZ LLC, Dubai, United Arab Emirates
| | - H. Haddadin
- Pfizer Gulf FZ LLC, Dubai, United Arab Emirates
| | - D. Mohty
- Heart Center, King Faisal Specialist Hospital, Riyadh, Saudi Arabia
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16
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Yu J, Kong F, Gao P, Chen T, Liu Y, Cheng Z, Deng H, Lai J, Zhang L, Fan J, Wang J, Qin X, Sun K, Li J, Fang Q, Yang D, Cheng K. Case Report: Left bundle branch pacing in an amyloid light-chain cardiac amyloidosis patient with atrioventricular block. Front Cardiovasc Med 2024; 10:1333484. [PMID: 38274319 PMCID: PMC10808645 DOI: 10.3389/fcvm.2023.1333484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 12/26/2023] [Indexed: 01/27/2024] Open
Abstract
Introduction Amyloid light-chain cardiac amyloidosis is a progressive infiltrative disease characterized by the deposition of amyloid fibrils in the cardiac tissue, which can cause serious atrioventricular block requiring pacemaker implantation. Left bundle branch pacing has emerged as an alternative method for delivering physiological pacing to achieve electrical synchrony of the left ventricle. However, left bundle branch pacing in patients with amyloid light-chain cardiac amyloidosis has not been studied in detail. Therefore, in this study, we present a case of left bundle branch pacing in a patient with amyloid light-chain cardiac amyloidosis. Case summary A 66-year-old male patient with amyloid light-chain cardiac amyloidosis presented with syncope for 1 month. Holter monitoring revealed intermittent third-degree atrioventricular block. Left bundle branch pacing was performed successfully. During the 1-year follow-up, it was observed that the left bundle branch capture threshold remained stable without any pacemaker-related complications or left ventricle systolic dysfunction, and there was no recurrence of syncope. Conclusion Left bundle branch pacing appears to be a safe and feasible option for patients with amyloid light-chain cardiac amyloidosis experiencing atrioventricular block.
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Affiliation(s)
- Jiaqi Yu
- Department of Internal Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Fanyi Kong
- Department of Gastroenterology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Peng Gao
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Taibo Chen
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Yongtai Liu
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Zhongwei Cheng
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Hua Deng
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jinzhi Lai
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Lihua Zhang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jingbo Fan
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jiaqi Wang
- Department of Internal Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Xiaohan Qin
- Department of Internal Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Keyue Sun
- Department of Internal Medicine, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Jian Li
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Quan Fang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Deyan Yang
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
| | - Kang’an Cheng
- Department of Cardiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, China
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17
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Saturi G, De Frutos F, Sguazzotti M, Gonzalez-Lopez E, Nardi E, Domínguez F, Ponziani A, Cabrera E, Caponetti AG, Lozano S, Massa P, Cobo-Marcos M, Accietto A, Castro-Urda V, Giovannetti A, Toquero J, Gagliardi C, Gómez-Bueno M, Rios-Tamayo R, Biagini E, Segovia J, Galiè N, García-Pavía P, Longhi S. Predictors and outcomes of pacemaker implantation in patients with cardiac amyloidosis. Heart 2023; 110:40-48. [PMID: 37414523 DOI: 10.1136/heartjnl-2022-322315] [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: 12/28/2022] [Accepted: 05/26/2023] [Indexed: 07/08/2023] Open
Abstract
OBJECTIVE We sought to investigate prevalence, incidence and prognostic implications of permanent pacemaker (PPM) implantation in patients with cardiac amyloidosis (CA), thereby identifying the predictors of time to PPM implantation. METHODS Seven hundred eighty-seven patients with CA (602 men, median age 74 years, 571 transthyretin amyloidosis (ATTR), 216 light-chain amyloidosis (AL)) evaluated at two European referral centres were retrospectively included. Clinical, laboratory and instrumental data were analysed. The associations between PPM implantation and mortality, heart failure (HF) or a composite endpoint of mortality, cardiac transplantation and HF were analysed. RESULTS 81 (10.3%) patients had a PPM before initial evaluation. Over a median follow-up time of 21.7 months (IQR 9.6-45.2), 81 (10.3%) additional patients (18 with AL (22.2%) and 63 with ATTR (77.8%)) underwent PPM implantation with a median time to implantation of 15.6 months (IQR 4.2-40), complete atrioventricular block was the most common indication (49.4%). Independent predictors of PPM implantation were QRS duration (HR 1.03, 95% CI 1.02 to 1.03, p<0.001) and interventricular septum (IVS) thickness (HR 1.1, 95% CI 1.03 to 1.17, p=0.003). The model to estimate the probability of PPM at 12 months and containing both factors showed a C-statistic of 0.71 and a calibration of slope of 0.98. CONCLUSIONS Conduction system disease requiring PPM is a common complication in CA that affects up to 20.6% of patients. QRS duration and IVS thickness are independently associated with PPM implantation. A PPM implantation at 12 months model was devised and validated to identify patients with CA at higher risk of requiring a PPM and who require closer follow-up.
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Affiliation(s)
- Giulia Saturi
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Fernando De Frutos
- Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain
| | - Maurizio Sguazzotti
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Esther Gonzalez-Lopez
- Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain
| | - Elena Nardi
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Fernando Domínguez
- Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain
| | - Alberto Ponziani
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Eva Cabrera
- Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain
| | - Angelo Giuseppe Caponetti
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Sara Lozano
- Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain
| | - Paolo Massa
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Marta Cobo-Marcos
- Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain
| | - Antonella Accietto
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Victor Castro-Urda
- Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain
| | - Alessandro Giovannetti
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Jorge Toquero
- Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain
| | - Christian Gagliardi
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Manuel Gómez-Bueno
- Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain
| | - Rafael Rios-Tamayo
- Department of Hematology, Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, Madrid, Spain
| | - Elena Biagini
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Javier Segovia
- Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain
| | - Nazzareno Galiè
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Pablo García-Pavía
- Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain
- Universidad Francisco de Vitoria, Pozuelo de Alarcon, Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Simone Longhi
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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Fumagalli C, Zampieri M, Argirò A, Tassetti L, Rossi G, Musumeci B, Tini G, Russo D, Sclafani M, Cipriani A, Sinigiani G, Di Bella G, Licordari R, Canepa M, Vianello PF, Merlo M, Porcari A, Rossi M, Sinagra G, Rapezzi C, Di Mario C, Ungar A, Olivotto I, Perfetto F, Cappelli F. Incidence and determinants of atrial fibrillation in patients with wild-type transthyretin cardiac amyloidosis. Int J Cardiol 2023; 392:131346. [PMID: 37689398 DOI: 10.1016/j.ijcard.2023.131346] [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] [Received: 08/25/2023] [Accepted: 09/04/2023] [Indexed: 09/11/2023]
Abstract
BACKGROUND Data on the incidence and factors associated with de novo atrial fibrillation (AF) in patients with wild-type transthyretin cardiac amyloidosis (ATTRwt-CA) is limited. We described the incidence and factors associated with de novo AF in patients diagnosed with ATTRwt-CA to drive tailored arrhythmia screening. METHODS Multicenter, retrospective, observational cohort study performed in six referral centers for CA. All consecutive patients diagnosed with ATTRwt-CA between 2004 and 2020 with >6-month follow up (FU) were enrolled and divided into three groups according to presence of AF: (1)patients with 'known AF'; (2)patients in 'sinus rhythm' and (3)patients developing 'de novo AF' during FU. Incidence and factors associated with AF in patients with ATTRwt were the primary outcomes. RESULTS Overall, 266 patients were followed for a median of 19 [11-33] months: 148 (56%) with known AF, 84 (31.6%) with sinus rhythm, and 34 (12.8%) with de novo AF. At Fine-Gray competing risk analysis to account for mortality, PR (sub-distribution hazard ratio [SHR] per Δms: 1.008, 95% C.I. 1.001-1.013, p = 0.008), QRS (SHR per Δms: 1.012, 95% C.I. 1.001-1.022, p = 0.046) and left atrial diameter ≥ 50 mm (SHR: 2.815,95% C.I. 1.483-5.342, p = 0.002) were associated with de novo AF. Patients with at least two risk factors (PR ≥ 200 ms, QRS ≥ 120 ms or LAD≥50 mm) had a higher risk of developing de novo AF compared to patients with no risk factors (HR 14.918 95% C.I. 3.242-31.646, p = 0.008). CONCLUSIONS At the end of the study almost 70% patients had AF. Longer PR and QRS duration and left atrial dilation are associated with arrhythmia onset.
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Affiliation(s)
- Carlo Fumagalli
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy; Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy; Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Mattia Zampieri
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy; Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Alessia Argirò
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy; Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy.
| | - Luigi Tassetti
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy; Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Gabriele Rossi
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy; Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Beatrice Musumeci
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sapienza University, Rome, Italy
| | - Giacomo Tini
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sapienza University, Rome, Italy
| | - Domitilla Russo
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sapienza University, Rome, Italy
| | - Matteo Sclafani
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sapienza University, Rome, Italy
| | - Alberto Cipriani
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Giulio Sinigiani
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | | | | | - Marco Canepa
- Cardiology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy; Department of Internal Medicine, University of Genoa, Italy
| | | | - Marco Merlo
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Italy
| | - Aldostefano Porcari
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Italy
| | - Maddalena Rossi
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Italy
| | - Gianfranco Sinagra
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Italy
| | - Claudio Rapezzi
- Cardiothoracic Department, University of Ferrara, Ferrara, Italy
| | - Carlo Di Mario
- Cardiothoracic and Vascular Department, Careggi University Hospital, Florence, Italy
| | - Andrea Ungar
- Department of Advanced Medical and Surgical Sciences, Università degli Studi della Campania "Luigi Vanvitelli", Naples, Italy
| | - Iacopo Olivotto
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Federico Perfetto
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Francesco Cappelli
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy; Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
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19
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Flore F, Scacciavillani R, Iannaccone G, Narducci ML, Pinnacchio G, Bencardino G, Perna F, Spera FR, Comerci G, Camilli M, Lombardo A, Lanza GA, Crea F, Pelargonio G. Mechanisms, prevalence and management of cardiac arrhythmias in cancer patients: a comprehensive review. Future Cardiol 2023; 19:707-718. [PMID: 37929680 DOI: 10.2217/fca-2023-0086] [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: 06/11/2023] [Accepted: 10/12/2023] [Indexed: 11/07/2023] Open
Abstract
Recently, prognosis and survival of cancer patients has improved due to progression and refinement of cancer therapies; however, cardiovascular sequelae in this population augmented and now represent the second cause of death in oncological patients. Initially, the main issue was represented by heart failure and coronary artery disease, but a growing body of evidence has now shed light on the increased arrhythmic risk of this population, atrial fibrillation being the most frequently encountered. Awareness of arrhythmic complications of cancer and its treatments may help oncologists and cardiologists to develop targeted approaches for the management of arrhythmias in this population. In this review, we provide an updated overview of the mechanisms triggering cardiac arrhythmias in cancer patients, their prevalence and management.
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Affiliation(s)
- Francesco Flore
- Department of Cardiovascular & Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Roberto Scacciavillani
- Department of Cardiovascular & Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy
| | - Giulia Iannaccone
- Department of Cardiovascular & Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Maria Lucia Narducci
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Gaetano Pinnacchio
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Gianluigi Bencardino
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Francesco Perna
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | | | - Gianluca Comerci
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Massimiliano Camilli
- Department of Cardiovascular & Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Antonella Lombardo
- Department of Cardiovascular & Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Gaetano Antonio Lanza
- Department of Cardiovascular & Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Filippo Crea
- Department of Cardiovascular & Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Gemma Pelargonio
- Department of Cardiovascular & Pulmonary Sciences, Catholic University of the Sacred Heart, 00168 Rome, Italy
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
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20
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Alhassan HA, Kainat A, Donohue J, Baumgartner SJ, Akunor H, Saba S, Jain S, Soman P. Safety of Catheter Ablation Therapy for Atrial Fibrillation in Cardiac Amyloidosis. J Am Heart Assoc 2023:e029339. [PMID: 37449569 PMCID: PMC10382095 DOI: 10.1161/jaha.122.029339] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 06/06/2023] [Indexed: 07/18/2023]
Abstract
Background Despite the high burden of atrial fibrillation in cardiac amyloidosis (CA), the safety of catheter ablation therapy in CA is not well established. We sought to examine short-term safety outcomes following atrial fibrillation ablation in patients with CA compared with matched patients with dilated cardiomyopathy (DCM). Methods and Results Using data from the National Inpatient Sample, we identified all hospitalizations for atrial fibrillation ablation from the fourth quarter of 2015 through 2019. Admissions for CA and DCM were matched in a 1:5 ratio using propensity scores based on the following sociodemographics: age, sex, race or ethnicity, payor, median income, comorbidities, and hospital characteristics. We compared in-hospital outcomes between both cardiomyopathies. We identified 1395 unweighted hospitalizations (representing 6750 national hospitalizations) for atrial fibrillation ablation, out of which 45 (3.2%) were admissions for CA. Compared with DCM, patients with CA were older (72.9 versus 65.1 years), had a higher burden of prior stroke (20.0% versus 8.6%) and chronic kidney disease (53.3% versus 33.6%), and were less likely to have a prior implantable cardioverter-defibrillator (4.4% versus 23.0%). We successfully matched 42 CAs to 210 DCM hospitalizations. After matching, there was no difference in total complications (14.3% versus 10.5%, P=0.60), length-of-stay (3.1 versus 2.1 days, P=0.23), home disposition (97.6% versus 96.2%, P=0.65), and total charges ($137 250 versus $133 910, P=0.24). Conclusions In this nationally representative study of atrial fibrillation catheter ablation in CA, short-term safety outcomes and complication rates were similar to a propensity score-matched cohort of DCM. Further studies exploring long-term safety outcomes are needed.
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Affiliation(s)
- Hassan A Alhassan
- Department of Medicine University of Pittsburgh Medical Center Pittsburgh PA USA
| | - Aleesha Kainat
- Department of Medicine University of Pittsburgh Medical Center McKeesport PA USA
| | - Joseph Donohue
- Department of Medicine University of Pittsburgh Medical Center Pittsburgh PA USA
| | - Scott J Baumgartner
- Department of Medicine University of Pittsburgh Medical Center Pittsburgh PA USA
| | - Harriet Akunor
- Department of Medicine Albert Einstein College of Medicine/Jacobi Medical Center Bronx NY USA
| | - Samir Saba
- Heart and Vascular Institute University of Pittsburgh Medical Center Pittsburgh PA USA
| | - Sandeep Jain
- Heart and Vascular Institute University of Pittsburgh Medical Center Pittsburgh PA USA
| | - Prem Soman
- Heart and Vascular Institute University of Pittsburgh Medical Center Pittsburgh PA USA
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21
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Knoll K, Fuchs P, Weidmann I, Altunkas F, Voss S, Lennerz C, Kolb C, Kessler T, Schunkert H, Reinhard W, Groß S, Trenkwalder T. Incidence and Predictors of Ventricular Arrhythmias in Transthyretin Amyloid Cardiomyopathy. J Clin Med 2023; 12:4624. [PMID: 37510739 PMCID: PMC10380522 DOI: 10.3390/jcm12144624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 06/29/2023] [Accepted: 07/03/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND Wild-type transthyretin amyloid cardiomyopathy (wtATTR-CM) is characterized by heart failure, conduction abnormalities and arrhythmias. The incidence of ventricular arrhythmias, particularly ventricular tachycardias (VTs), in wtATTR-CM is unclear. With the development of targeted therapies and improved overall prognosis, there is an unmet need to identify patients at high risk for VTs who might benefit from ICD therapy. METHODS Between 2017 and 2022, 72 patients diagnosed with wtATTR-CM were prospectively evaluated for the presence of ventricular arrhythmias using a Holter ECG. VTs were defined as >3 consecutive beats with a heart rate > 100 beats per minute originating from a ventricle. RESULTS The incidence of VTs was 44% (n = 32/72) in unselected wtATTR-CM patients. Patients with VT showed significantly more severe left ventricular (LV) hypertrophy (septum diameter 21 ± 2.6 vs. 19 ± 3.0 mm, p = 0.006), reduced LV ejection fraction (47 ± 8 vs. 52 ± 8%, p = 0.014) and larger left atria (32 ± 7 vs. 28 ± 6 mm2, p = 0.020), but no differences in cardiac markers such as NTproBNP and troponin. In a multivariable model, LV hypertrophy (LV mass indexed, OR = 1.02 [1.00-1.03], p = 0.031), LV end-diastolic diameter (OR = 0.85 [0.74-0.98], p = 0.021) and LV end-systolic diameter (OR = 1.19 [1.03-1.349], p = 0.092) were predictive for VT occurrence with an area under the receiver operating characteristic of 0.76 [0.65-0.87]. CONCLUSIONS The incidence of ventricular arrhythmia in wtATTR-CM is high and is associated with an advanced stage of left ventricular disease. Further studies are needed evaluating the role of VTs in predicting sudden cardiac death and the benefit of ICD therapy in wtATTR-CM.
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Affiliation(s)
- Katharina Knoll
- German Heart Centre Munich, Department of Cardiology, Technical University of Munich, 80333 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, 80336 Munich, Germany
| | - Patrick Fuchs
- German Heart Centre Munich, Department of Cardiology, Technical University of Munich, 80333 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, 80336 Munich, Germany
| | - Isabel Weidmann
- German Heart Centre Munich, Department of Cardiology, Technical University of Munich, 80333 Munich, Germany
| | - Fatih Altunkas
- German Heart Centre Munich, Department of Cardiology, Technical University of Munich, 80333 Munich, Germany
| | - Stephanie Voss
- German Heart Centre Munich, Department of Cardiovascular Surgery, Technical University of Munich, 80636 Munich, Germany
| | - Carsten Lennerz
- German Heart Centre Munich, Department of Cardiology, Technical University of Munich, 80333 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, 80336 Munich, Germany
| | - Christof Kolb
- German Heart Centre Munich, Department of Cardiology, Technical University of Munich, 80333 Munich, Germany
| | - Thorsten Kessler
- German Heart Centre Munich, Department of Cardiology, Technical University of Munich, 80333 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, 80336 Munich, Germany
| | - Heribert Schunkert
- German Heart Centre Munich, Department of Cardiology, Technical University of Munich, 80333 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, 80336 Munich, Germany
| | - Wibke Reinhard
- German Heart Centre Munich, Department of Cardiology, Technical University of Munich, 80333 Munich, Germany
| | - Stefan Groß
- DZHK (German Centre for Cardiovascular Research), Partner Site Greifswald, 17475 Greifswald, Germany
- Department of Internal Medicine B, University Medicine Greifswald, 17475 Greifswald, Germany
| | - Teresa Trenkwalder
- German Heart Centre Munich, Department of Cardiology, Technical University of Munich, 80333 Munich, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Munich Heart Alliance, 80336 Munich, Germany
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22
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Nomoto Y, Kataoka N, Imamura T. How to treat atrial fibrillation in patients with cardiac amyloidosis. EUROPEAN HEART JOURNAL OPEN 2023; 3:oead071. [PMID: 37465257 PMCID: PMC10351497 DOI: 10.1093/ehjopen/oead071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 06/09/2023] [Indexed: 07/20/2023]
Affiliation(s)
- Yu Nomoto
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani Toyama, Toyama 930-0194, Japan
| | - Naoya Kataoka
- Second Department of Internal Medicine, University of Toyama, 2630 Sugitani Toyama, Toyama 930-0194, Japan
| | - Teruhiko Imamura
- Corresponding author. Tel: +81 76 434 2281, Fax: +81 76 434 5026,
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23
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Bukhari S, Oliveros E, Parekh H, Farmakis D. Epidemiology, Mechanisms, and Management of Atrial Fibrillation in Cardiac Amyloidosis. Curr Probl Cardiol 2023; 48:101571. [PMID: 36584731 DOI: 10.1016/j.cpcardiol.2022.101571] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 12/23/2022] [Indexed: 12/29/2022]
Abstract
Cardiac amyloidosis (CA) is a restrictive disease that results from intramyocardial amyloid deposition due to immunoglobulin light chain or transthyretin proteins. Up to two-third of CA patients have atrial fibrillation (AF) due to electromechanical, autonomic, and hemodynamic disturbances. AF in CA carries particularly increased risk of thromboembolism, prompting anticoagulation therapy irrespective of CHA2DS2VASc score. However, CA is also associated with enhanced bleeding risk that warrants thorough assessment of bleeding profile before initiation of anticoagulation. Management of AF in CA is challenging because these patients poorly tolerate rate control agents, while cardiomyopathy precludes most antiarrhythmic agents, leaving amiodarone as the preferred antiarrhythmic drug. The effectiveness of direct current cardioversion in restoring sinus rhythm in CA is comparable with that in the general population, although intraprocedural complication rates could be higher. Transesophageal echocardiogram should be performed prior to direct current cardioversion, given high incidence of intracardiac thrombus in these patients. Finally, the data on catheter ablation is limited.
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24
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Laptseva N, Rossi VA, Sudano I, Schwotzer R, Ruschitzka F, Flammer AJ, Duru F. Arrhythmic Manifestations of Cardiac Amyloidosis: Challenges in Risk Stratification and Clinical Management. J Clin Med 2023; 12:jcm12072581. [PMID: 37048664 PMCID: PMC10095126 DOI: 10.3390/jcm12072581] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/23/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023] Open
Abstract
Amylodiosis is a systemic disease characterized by extracellular deposits of insoluble amyloid in various tissues and organs. Cardiac amyloidosis is a frequent feature of the disease, causing a progressive, restrictive type of cardiomyopathy, and is associated with adverse clinical outcomes and increased mortality. The typical clinical presentation in patients with cardiac amyloidosis is heart failure (HF) with preserved ejection fraction. Most patients present with typical symptoms and signs of HF, such as exertional dyspnea, pretibial edema, pleural effusions and angina pectoris due to microcirculatory dysfunction. However, patients may also frequently encounter various arrhythmias, such as atrioventricular nodal block, atrial fibrillation and ventricular tachyarrhythmias. The management of arrhythmias in cardiac amyloidosis patients with drugs and devices is often a clinical challenge. Moreover, predictors of life-threatening arrhythmic events are not well defined. This review intends to give a deepened insight into the arrhythmic features of cardiac amyloidosis by discussing the pathogenesis of these arrhythmias, addressing the challenges in risk stratification and strategies for management in these patients.
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25
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Scirpa R, Cittadini E, Mazzocchi L, Tini G, Sclafani M, Russo D, Imperatrice A, Tropea A, Autore C, Musumeci B. Risk stratification in transthyretin-related cardiac amyloidosis. Front Cardiovasc Med 2023; 10:1151803. [PMID: 37025682 PMCID: PMC10070959 DOI: 10.3389/fcvm.2023.1151803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 03/06/2023] [Indexed: 04/08/2023] Open
Abstract
Transthyretin related cardiac amyloidosis (TTR-CA) is an infiltrative cardiomyopathy that cause heart failure with preserved ejection fraction, mainly in aging people. Due to the introduction of a non invasive diagnostic algorithm, this disease, previously considered to be rare, is increasingly recognized. The natural history of TTR-CA includes two different stages: a presymptomatic and a symptomatic stage. Due to the availability of new disease-modifying therapies, the need to reach a diagnosis in the first stage has become impelling. While in variant TTR-CA an early identification of the disease may be obtained with a genetic screening in proband's relatives, in the wild-type form it represents a challenging issue. Once the diagnosis has been made, in order to identifying patients with a higher risk of cardiovascular events and death it is necessary to focus on risk stratification. Two prognostic scores have been proposed both based on biomarkers and laboratory findings. However, a multiparametric approach combining information from electrocardiogram, echocardiogram, cardiopulmonary exercise test and cardiac magnetic resonance may be warranted for a more comprehensive risk prediction. In this review, we aim at evaluating a step by step risk stratification, providing a clinical diagnostic and prognostic approach for the management of patients with TTR-CA.
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Affiliation(s)
- Riccardo Scirpa
- Division of Cardiology, Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Edoardo Cittadini
- Division of Cardiology, Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Lorenzo Mazzocchi
- Division of Cardiology, Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Giacomo Tini
- Division of Cardiology, Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
- Department of Cardiology, IRCCS San Raffaele Pisana, Rome, Italy
| | - Matteo Sclafani
- Division of Cardiology, Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Domitilla Russo
- Division of Cardiology, Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Andrea Imperatrice
- Division of Cardiology, Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | - Alessandro Tropea
- Division of Cardiology, Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
| | | | - Beatrice Musumeci
- Division of Cardiology, Department of Clinical and Molecular Medicine, Sapienza University of Rome, Rome, Italy
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26
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Abstract
Amyloidosis is a pathologic and clinical condition resulting from the accumulation of insoluble aggregates of misfolded proteins in tissues. Extracellular deposition of amyloid fibrils in the myocardium leads to cardiac amyloidosis, which is often overlooked as a cause of diastolic heart failure. Although cardiac amyloidosis was previously believed to have a poor prognosis, recent advances in diagnosis and treatment have emphasized the importance of early recognition and changed management of this condition. This article provides an overview of cardiac amyloidosis and summarizes current screening, diagnosis, evaluation, and treatment options.
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Affiliation(s)
- Michelle Weisfelner Bloom
- Division of Cardiology, Renaissance School of Medicine, State University of New York at Stony Brook, Stony Brook, New York (M.W.B.)
| | - Peter D Gorevic
- Division of Rheumatology, Renaissance School of Medicine, State University of New York at Stony Brook, Stony Brook, New York (P.D.G.)
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27
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Frustaci A, Verardo R, Russo MA, Caldarulo M, Alfarano M, Galea N, Miraldi F, Chimenti C. Infiltration of Conduction Tissue Is a Major Cause of Electrical Instability in Cardiac Amyloidosis. J Clin Med 2023; 12:jcm12051798. [PMID: 36902585 PMCID: PMC10003445 DOI: 10.3390/jcm12051798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 02/20/2023] [Accepted: 02/22/2023] [Indexed: 03/12/2023] Open
Abstract
BACKGROUND The pathology of conduction tissue (CT) and relative arrhythmias in living subjects with cardiac amyloid have never been reported. AIMS To report CT pathology and its arrhythmic correlations in human cardiac amyloidosis. METHODS AND RESULTS In 17 out of 45 cardiac amyloid patients, a left ventricular endomyocardial biopsy included conduction tissue sections. It was identified by Aschoff-Monckeberg histologic criteria and positive immunostaining for HCN4. The degree of conduction tissue infiltration was defined as mild when ≤30%, moderate when 30-70% and severe when >70% cell area was replaced. Conduction tissue infiltration was correlated with ventricular arrhythmias, maximal wall thickness and type of amyloid protein. Mild involvement was observed in five cases, moderate in three and severe in nine. Involvement was associated with a parallel infiltration of conduction tissue artery. Conduction infiltration correlated with the severity of arrhythmias (Spearman rho = 0.8, p < 0.001). In particular, major ventricular tachyarrhythmias requiring pharmacologic treatment or ICD implantation occurred in seven patients with severe, one patient with moderate and none with mild conduction tissue infiltration. Pacemaker implantation was required in three patients, with complete conduction section replacement. No significant correlation was observed between the degree of conduction infiltration and age, cardiac wall thickness or type of amyloid protein. CONCLUSIONS Amyloid-associated cardiac arrhythmias correlate with the extent of conduction tissue infiltration. Its involvement is independent from type and severity of amyloidosis, suggesting a variable affinity of amyloid protein to conduction tissue.
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Affiliation(s)
- Andrea Frustaci
- Cellular and Molecular Cardiology Lab, IRCCS L. Spallanzani, Via Portuense 292, 00149 Rome, Italy
- Correspondence: ; Tel.: +39-06-5517-0520
| | - Romina Verardo
- Cellular and Molecular Cardiology Lab, IRCCS L. Spallanzani, Via Portuense 292, 00149 Rome, Italy
| | - Matteo Antonio Russo
- MEBIC Consortium, San Raffaele Open University, 00166 Rome, Italy
- Cellular and Molecular Pathology, IRCCS San Raffaele, 00166 Rome, Italy
| | - Marina Caldarulo
- Cellular and Molecular Cardiology Lab, IRCCS L. Spallanzani, Via Portuense 292, 00149 Rome, Italy
| | - Maria Alfarano
- Department of Clinical Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University, 00185 Rome, Italy
| | - Nicola Galea
- Department of Experimental Medicine, Sapienza University, 00185 Rome, Italy
| | - Fabio Miraldi
- Department of Clinical Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University, 00185 Rome, Italy
| | - Cristina Chimenti
- Department of Clinical Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University, 00185 Rome, Italy
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28
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Caponetti AG, Accietto A, Saturi G, Ponziani A, Sguazzotti M, Massa P, Giovannetti A, Ditaranto R, Parisi V, Leone O, Guaraldi P, Cortelli P, Gagliardi C, Longhi S, Galiè N, Biagini E. Screening approaches to cardiac amyloidosis in different clinical settings: Current practice and future perspectives. Front Cardiovasc Med 2023; 10:1146725. [PMID: 36970351 PMCID: PMC10033591 DOI: 10.3389/fcvm.2023.1146725] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 02/20/2023] [Indexed: 03/29/2023] Open
Abstract
Cardiac amyloidosis is a serious and progressive infiltrative disease caused by the deposition of amyloid fibrils in the heart. In the last years, a significant increase in the diagnosis rate has been observed owing to a greater awareness of its broad clinical presentation. Cardiac amyloidosis is frequently associated to specific clinical and instrumental features, so called "red flags", and it appears to occur more commonly in particular clinical settings such as multidistrict orthopedic conditions, aortic valve stenosis, heart failure with preserved or mildly reduced ejection fraction, arrhythmias, plasma cell disorders. Multimodality approach and new developed techniques such PET fluorine tracers or artificial intelligence may contribute to strike up extensive screening programs for an early recognition of the disease.
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Affiliation(s)
- Angelo Giuseppe Caponetti
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Antonella Accietto
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Giulia Saturi
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Alberto Ponziani
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Maurizio Sguazzotti
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Paolo Massa
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Alessandro Giovannetti
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Raffaello Ditaranto
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Vanda Parisi
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Ornella Leone
- Department of Pathology, Cardiovascular and Cardiac Transplant Pathology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Pietro Guaraldi
- IRCCS Istituto Delle Scienze Neurologiche di Bologna, Bologna, Italy
| | - Pietro Cortelli
- IRCCS Istituto Delle Scienze Neurologiche di Bologna, Bologna, Italy
- Department of Biomedical and NeuroMotor Sciences (DiBiNeM), Alma Mater Studiorum-University of Bologna, Bologna, Italy
| | - Christian Gagliardi
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Bologna, Italy
| | - Simone Longhi
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Bologna, Italy
| | - Nazzareno Galiè
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Elena Biagini
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Bologna, Italy
- Correspondence: Elena Biagini
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29
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Martens P, Hanna M, Valent J, Mullens W, Ives L, Kwon DH, Rickard J, Tang WHW. Electrical Dyssynchrony in Cardiac Amyloidosis: Prevalence, Predictors, Clinical Correlates, and Outcomes. J Card Fail 2022; 28:1664-1672. [PMID: 35882259 DOI: 10.1016/j.cardfail.2022.07.046] [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: 04/23/2022] [Revised: 07/06/2022] [Accepted: 07/06/2022] [Indexed: 10/16/2022]
Abstract
BACKGROUND Conduction-system involvement in cardiac amyloidosis (CA) is common. The prevalence, clinical correlates and impact on outcome related to ventricular electrical dyssynchrony in CA remain insufficiently elucidated. METHODS Data from a prospectively maintained registry of patients with CA diagnosed in the Cleveland Clinic's amyloidosis clinic was used to determine the frequency of electrical dyssynchrony (defined as a QRS > 130 msec). The relation with the clinical profile and clinical outcome was assessed. To determine the impact of hypertrophy on QRS prolongation, a QRS-matched cohort without CA was used for comparison of cardiac magnetic resonance imaging. RESULTS A total of 1140 patients with CA (39% AL, 61% TTR) were evaluated, of whom 230 (20%) had electrical dyssynchrony. The type of conduction block was predominantly a right bundle branch block (BBB, 48%) followed by left BBB (35%) and intraventricular conduction delay (17%). Presence of transthyretin amyloidosis (ATTR-CA), older age, male gender, white race, and coronary artery disease were independently (P< 0.05 for all) associated with electrical dyssynchrony, and patients were more commonly prescribed a mineralocorticoid receptor antagonist. In ATTR-CA, specifically, every increase in ATTR-CA disease stage was associated with a 1.55-fold (1.23--1.95; P< 0.001) increased odds for electrical dyssynchrony. In a subset of patients with CA who underwent cardiac magnetic resonance imaging (n = 41), left ventricular mass index was unrelated to the QRS duration (r = 0.187; P = 0.283) in CA, in contrast to a non-CA QRS-matched cohort (r = 0.397; P< 0.001). Patients with electrical dyssynchrony were more symptomatic at initial presentation, as illustrated by a higher New York Heart Association class (P= 0.041). During a median follow-up of 462 days (IQR:138--996 days), a higher proportion of patients with electrical dyssynchrony died from all-cause death (P= 0.037) or developed a permanent pacing indication (3% vs 10.4%; P< 0.001) during follow-up. CONCLUSION Electrical dyssynchrony is common in CA, especially in ATTR-CA, and is associated with worse functional status and clinical outcome. Given the high rate of permanent pacing indications at follow-up, additional studies are necessary to determine the best monitoring and pacing strategies in CA.
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Affiliation(s)
- Pieter Martens
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA; Department of Cardiology, Ziekenhuis Oost Limburg, Genk, Belgium and University Hasselt, Belgium.
| | - Mazen Hanna
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jason Valent
- Department of Hematology and Medical Oncology, Taussig Cancer Institute, Cleveland Clinic, Cleveland Ohio, USA
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost Limburg, Genk, Belgium and University Hasselt, Belgium
| | - Lauren Ives
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Debbie H Kwon
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - John Rickard
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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30
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Schneider SM, Kochar K, Ruge M, Marek-Iannucci S, Datta T, Hajduczok A, Ullah W, Rajapreyar I, Brailovsky Y. Cardiogenic Shock Due to Atrial Arrhythmia as the Initial Presentation of Transthyretin Cardiac Amyloidosis. JACC Case Rep 2022; 4:1490-1495. [PMID: 36444185 PMCID: PMC9700062 DOI: 10.1016/j.jaccas.2022.07.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 07/12/2022] [Accepted: 07/19/2022] [Indexed: 06/16/2023]
Abstract
Atrial arrhythmias are common in transthyretin cardiac amyloidosis (ATTR-CA), with a prevalence of ≤80%. They are often not well tolerated. We describe 3 patients with decompensated heart failure and cardiogenic shock precipitated by atrial arrhythmias who ultimately received diagnoses of ATTR-CA. (Level of Difficulty: Intermediate.).
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Affiliation(s)
- Svenja M. Schneider
- Department of Internal Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Kirpal Kochar
- Department of Internal Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Max Ruge
- Department of Internal Medicine, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Stefanie Marek-Iannucci
- Division of Cardiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Tanuka Datta
- Division of Cardiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Alexander Hajduczok
- Division of Cardiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Waqas Ullah
- Division of Cardiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Indranee Rajapreyar
- Division of Cardiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Yevgeniy Brailovsky
- Division of Cardiology, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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31
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Argirò A, Del Franco A, Mazzoni C, Allinovi M, Tomberli A, Tarquini R, Di Mario C, Perfetto F, Cappelli F, Zampieri M. Arrhythmic Burden in Cardiac Amyloidosis: What We Know and What We Do Not. Biomedicines 2022; 10:2888. [PMID: 36359408 PMCID: PMC9687719 DOI: 10.3390/biomedicines10112888] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 10/31/2022] [Accepted: 11/08/2022] [Indexed: 08/26/2023] Open
Abstract
Cardiac amyloidosis (CA), caused by the deposition of insoluble amyloid fibrils, impairs different cardiac structures, altering not only left ventricle (LV) systo-diastolic function but also atrial function and the conduction system. The consequences of the involvement of the cardiac electrical system deserve more attention, as well as the study of the underlying molecular mechanisms. This is an issue of considerable interest, given the conflicting data on the effectiveness of conventional antiarrhythmic strategies. Therefore, this review aims at summarizing the arrhythmic burden related to CA and the available evidence on antiarrhythmic treatment in this population.
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Affiliation(s)
- Alessia Argirò
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, 50134 Florence, Italy
| | - Annamaria Del Franco
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, 50134 Florence, Italy
| | - Carlotta Mazzoni
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, 50134 Florence, Italy
| | - Marco Allinovi
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, 50134 Florence, Italy
| | - Alessia Tomberli
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, 50134 Florence, Italy
| | - Roberto Tarquini
- Department of Internal Medicine I, San Giuseppe Hospital, 50053 Empoli, Italy
| | - Carlo Di Mario
- Structural Interventional Cardiology Department, Careggi University Hospital, 50134 Florence, Italy
| | - Federico Perfetto
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, 50134 Florence, Italy
| | - Francesco Cappelli
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, 50134 Florence, Italy
| | - Mattia Zampieri
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, 50134 Florence, Italy
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32
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Cammalleri V, De Luca VM, Antonelli G, Annibali O, Nusca A, Mega S, Carpenito M, Ricciardi D, Gurrieri F, Avvisati G, Ussia GP, Grigioni F. Emerging from the Darkness. Sudden Cardiac Death in Cardiac Amyloidosis. Rev Cardiovasc Med 2022; 23:345. [PMID: 39077150 PMCID: PMC11267335 DOI: 10.31083/j.rcm2310345] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 09/12/2022] [Accepted: 09/13/2022] [Indexed: 07/31/2024] Open
Abstract
Cardiac amyloidosis (CA) manifests as infiltrative cardiomyopathy with a hypertrophic pattern, usually presenting with heart failure with a preserved ejection fraction. In addition, degenerative valvular heart disease, particularly severe aortic stenosis, is commonly seen in patients with CA. However, amyloid fibril deposition might also infiltrate the conduction system and promote the development of electrical disorders, including ventricular tachyarrhythmias, atrio-ventricular block or acute electromechanical dissociation. These manifestations can increase the risk of sudden cardiac death. This review summarises the pathophysiological mechanisms and risk factors for sudden cardiac death in CA and focuses on the major current concerns regarding medical and device management in this challenging scenario.
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Affiliation(s)
- Valeria Cammalleri
- Fondazione Policlinico Universitario Campus-Biomedico, Operative Research Unit of Cardiovascular Science, 00128 Roma, Italy
| | - Valeria Maria De Luca
- Department of Cardiovascular Science, Università Campus Bio-Medico di Roma, 00128 Roma, Italy
| | - Giorgio Antonelli
- Department of Cardiovascular Science, Università Campus Bio-Medico di Roma, 00128 Roma, Italy
| | - Ombretta Annibali
- Department of Haematology, Università Campus Bio-Medico di Roma, 00128 Rome, Italy
| | - Annunziata Nusca
- Fondazione Policlinico Universitario Campus-Biomedico, Operative Research Unit of Cardiovascular Science, 00128 Roma, Italy
| | - Simona Mega
- Fondazione Policlinico Universitario Campus-Biomedico, Operative Research Unit of Cardiovascular Science, 00128 Roma, Italy
| | - Myriam Carpenito
- Fondazione Policlinico Universitario Campus-Biomedico, Operative Research Unit of Cardiovascular Science, 00128 Roma, Italy
| | - Danilo Ricciardi
- Fondazione Policlinico Universitario Campus-Biomedico, Operative Research Unit of Cardiovascular Science, 00128 Roma, Italy
| | - Fiorella Gurrieri
- Laboratory of Medical Genetics, Università Campus Bio-Medico di Roma, 00128 Rome, Italy
| | - Giuseppe Avvisati
- Department of Haematology, Università Campus Bio-Medico di Roma, 00128 Rome, Italy
| | - Gian Paolo Ussia
- Fondazione Policlinico Universitario Campus-Biomedico, Operative Research Unit of Cardiovascular Science, 00128 Roma, Italy
- Department of Cardiovascular Science, Università Campus Bio-Medico di Roma, 00128 Roma, Italy
| | - Francesco Grigioni
- Fondazione Policlinico Universitario Campus-Biomedico, Operative Research Unit of Cardiovascular Science, 00128 Roma, Italy
- Department of Cardiovascular Science, Università Campus Bio-Medico di Roma, 00128 Roma, Italy
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33
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Dominguez F. Predicting pacemaker implantation in cardiac amyloidosis: Let's start with an ECG. Eur J Heart Fail 2022; 24:1237-1238. [PMID: 35726632 DOI: 10.1002/ejhf.2591] [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: 06/03/2022] [Accepted: 06/18/2022] [Indexed: 11/08/2022] Open
Affiliation(s)
- Fernando Dominguez
- Heart Failure and Inherited Cardiac Diseases Unit. Department of Cardiology. Hospital Universitario Puerta de Hierro Madrid.,Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV)
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34
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Porcari A, Rossi M, Cappelli F, Canepa M, Musumeci B, Cipriani A, Tini G, Barbati G, Varrà GG, Morelli C, Fumagalli C, Zampieri M, Argirò A, Vianello PF, Sessarego E, Russo D, Sinigiani G, De Michieli L, Di Bella G, Autore C, Perfetto F, Rapezzi C, Sinagra G, Merlo M. Incidence and Risk Factors for Pacemaker Implantation in Light Chain and Transthyretin Cardiac Amyloidosis. Eur J Heart Fail 2022; 24:1227-1236. [PMID: 35509181 DOI: 10.1002/ejhf.2533] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 05/01/2022] [Accepted: 05/02/2022] [Indexed: 11/12/2022] Open
Abstract
AIMS The incidence and risk factors of pacemaker (PM) implantation in patients with cardiac amyloidosis (CA) are largely unexplored. We sought to characterise the trends in the incidence of permanent PM and to identify baseline predictors of future PM implantation in light chain (AL) and transthyretin (ATTR) CA. METHODS AND RESULTS Consecutive patients with AL and ATTR-CA diagnosed at participating Centres (2017-2020) were included. Clinical data recorded within ±1 month from diagnosis were collected from electronic medical records. The primary study outcome was the need for clinically-indicated PM implantation. Patients with PM (n = 41) and/or permanent defibrillator in situ (n = 13) at CA diagnosis were excluded. The study population consisted of 405 patients: 29.4% AL, 14.6% variant ATTR and 56% wild-type ATTR; 82.5% were males, median age 76 years. During a median follow-up of 33 months (interquartile range 21-46), 36 (8.9%) patients experienced the primary outcome: 10 AL-CA, 2 variant ATTR-CA and 24 wild-type ATTR-CA (p = 0.08 at time-to-event analysis). At multivariable analysis, history of atrial fibrillation (hazard ratio [HR] 3.80, p = 0.002), PR interval (HR 1.013, p = 0.002) and QRS >120 ms (HR 4.7, p = 0.001) on baseline ECG were independently associated with PM implantation. The absence of these 3 factors had a negative predictive value of 92% with an area under the curve of 91.8% at 6 months. CONCLUSION In a large cohort of AL and ATTR-CA patients, 8.9% implanted a PM in the 3 years following diagnosis. History of atrial fibrillation, PR >200 ms and QRS >120 ms predicted future PM implantation.
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Affiliation(s)
- Aldostefano Porcari
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Italy
| | - Maddalena Rossi
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Italy
| | - Francesco Cappelli
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy.,Cardiomyopathy Unit, Careggi University Hospital, University of Florence, Florence, Italy
| | - Marco Canepa
- Cardiovascular Unit, Department of Internal Medicine, University of Genova, Ospedale Policlinico San Martino IRCCS, Genova, Italy
| | - Beatrice Musumeci
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sapienza University, Rome, Italy
| | - Alberto Cipriani
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Giacomo Tini
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sapienza University, Rome, Italy
| | - Giulia Barbati
- Department of Medical Sciences, Biostatistics Unit, University of Trieste, Trieste, Italy
| | - Guerino Giuseppe Varrà
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Italy
| | - Cristina Morelli
- Cardiomyopathy Unit, Careggi University Hospital, University of Florence, Florence, Italy
| | - Carlo Fumagalli
- Cardiomyopathy Unit, Careggi University Hospital, University of Florence, Florence, Italy
| | - Mattia Zampieri
- Cardiomyopathy Unit, Careggi University Hospital, University of Florence, Florence, Italy
| | - Alessia Argirò
- Cardiomyopathy Unit, Careggi University Hospital, University of Florence, Florence, Italy
| | - Pier Filippo Vianello
- Cardiovascular Unit, Department of Internal Medicine, University of Genova, Ospedale Policlinico San Martino IRCCS, Genova, Italy
| | - Eugenio Sessarego
- Cardiovascular Unit, Department of Internal Medicine, University of Genova, Ospedale Policlinico San Martino IRCCS, Genova, Italy
| | - Domitilla Russo
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sapienza University, Rome, Italy
| | - Giulio Sinigiani
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | - Laura De Michieli
- Department of Cardiac, Thoracic and Vascular Sciences and Public Health, University of Padua, Padua, Italy
| | | | - Camillo Autore
- Department of Clinical and Molecular Medicine, Faculty of Medicine and Psychology, Sapienza University, Rome, Italy
| | - Federico Perfetto
- Cardiomyopathy Unit, Careggi University Hospital, University of Florence, Florence, Italy
| | - Claudio Rapezzi
- Cardiothoracic Department, University of Ferrara, Ferrara, Italy.,Maria Cecilia Hospital, GVM Care & Research, Cotignola, Ravenna, Italy
| | - Gianfranco Sinagra
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Italy
| | - Marco Merlo
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Italy
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35
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Salinas-Arce J, Alca-Clares R, Gonzales-Luna AC, Cabrera-Saldaña M, Mendoza-Novoa P, Solórzano-Altamirano P, Guevara-Valdivia M. [Cardiac arrhythmias and amyloidosis]. ARCHIVOS PERUANOS DE CARDIOLOGIA Y CIRUGIA CARDIOVASCULAR 2022; 3:82-97. [PMID: 37351307 PMCID: PMC10284580 DOI: 10.47487/apcyccv.v3i2.217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 06/27/2022] [Indexed: 06/24/2023]
Abstract
Cardiac amyloidosis (CA) is a form of cardiomyopathy characterized by the extracellular deposit of protein fibers in the myocardium, leading to the development of heart failure, arrhythmias, and electrical conduction system alterations. It is known that most cardiomyopathies have a close relationship with heart rhythm abnormalities, however, CA is specially related to different kinds of arrhythmias even in pre-diagnosis stages. Arrhythmias like atrial fibrillation are present in up to 70% of patients with CA associated with a high risk of cardioembolic complications independent of the risk stratification. Ventricular arrhythmias are frequent, but the use of implantable cardioverter defibrillator has not been demonstrated to improve survival. The Atrial-Ventricular node disease is also common, and is frequently associated with the implantation of a pacemaker, even in asymptomatic patients. In this review, we clarify the recommendations of the most current guidelines, summarize historical and contemporaneous data and describe evidence-based strategies for the management of arrhythmias and their complications in CA.
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Affiliation(s)
- Jorge Salinas-Arce
- Unidad de Arritmias, Clínica Delgado. Lima, Perú.Unidad de ArritmiasClínica DelgadoLimaPerú
| | - Raúl Alca-Clares
- Unidad de Arritmias, Clínica Delgado. Lima, Perú.Unidad de ArritmiasClínica DelgadoLimaPerú
- . Servicio de Cardiología, Hospital Cayetano Heredia. Lima, Perú.Servicio de CardiologíaHospital Cayetano HerediaLimaPerú
| | - Ana Cecilia Gonzales-Luna
- Unidad de Arritmias, Clínica Delgado. Lima, Perú.Unidad de ArritmiasClínica DelgadoLimaPerú
- . Unidad de Arritmias, Hospital Edgardo Rebagliati. Lima, Perú.Unidad de ArritmiasHospital Edgardo RebagliatiLimaPerú
| | - Mario Cabrera-Saldaña
- Unidad de Arritmias, Clínica Delgado. Lima, Perú.Unidad de ArritmiasClínica DelgadoLimaPerú
- . Unidad de Arritmias, Servicio de Cardiología Invasiva, Instituto Nacional Cardiovascular - INCOR EsSalud. Lima, Perú.Unidad de ArritmiasServicio de Cardiología InvasivaInstituto Nacional Cardiovascular - INCOR EsSaludLimaPerú
| | - Pablo Mendoza-Novoa
- Unidad de Arritmias, Clínica Delgado. Lima, Perú.Unidad de ArritmiasClínica DelgadoLimaPerú
- . Unidad de Arritmias, Hospital del Niño. Lima, Perú.Unidad de ArritmiasHospital del NiñoLimaPerú
| | - Paula Solórzano-Altamirano
- . Unidad de Docencia en Arritmias, APSA-QRS VITAL. Lima, Perú.Unidad de Docencia en ArritmiasAPSA-QRS VITALLimaPerú
| | - Milton Guevara-Valdivia
- . Departamento de Electrofisiología Cardiaca, Unidad Médica de Alta Especialidad del Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social. Ciudad de México, México.Instituto Mexicano del Seguro SocialDepartamento de Electrofisiología Cardiaca, Unidad Médica de Alta Especialidad del Hospital de Especialidades Dr. Antonio Fraga MouretCentro Médico Nacional La RazaInstituto Mexicano del Seguro SocialCiudad de MéxicoMexico
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