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Badwan O, Berglund F, Rosenzveig A, Persits I, Gharaibeh A, Kumar A, Agrawal A, Sul L, Chan N, Wang TKM, Hanna M, Klein AL. Pericardial Disease in Cardiac Amyloidosis: A Comprehensive Review. Am J Cardiol 2024; 223:100-108. [PMID: 38740164 DOI: 10.1016/j.amjcard.2024.05.007] [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: 01/28/2024] [Revised: 05/02/2024] [Accepted: 05/08/2024] [Indexed: 05/16/2024]
Abstract
In patients with cardiac amyloidosis, pericardial involvement is common, with up to half of patients presenting with pericardial effusions. The pathophysiological mechanisms of pericardial pathology in cardiac amyloidosis include chronic elevations in right-sided filling pressures, myocardial and pericardial inflammation due to cytotoxic effects of amyloid deposits, and renal involvement with subsequent uremia and hypoalbuminemia. The pericardial effusions are typically small; however, several cases of life-threatening cardiac tamponade with hemorrhagic effusions have been described as a presenting clinical scenario. Constrictive pericarditis can also occur due to amyloidosis and its identification presents a clinical challenge in patients with cardiac amyloidosis who concurrently manifest signs of restrictive cardiomyopathy. Multimodality imaging, including echocardiography, cardiac computed tomography, and cardiac magnetic resonance imaging, is useful in the evaluation and management of this patient population. The recognition of pericardial effusion is important in the risk stratification of patients with cardiac amyloidosis as its presence confers a poor prognosis. However, specific treatment aimed at the effusions themselves is seldom indicated. Cardiac tamponade and constrictive pericarditis may necessitate pericardiocentesis and pericardiectomy, respectively.
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Affiliation(s)
- Osamah Badwan
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Felix Berglund
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell, and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Akiva Rosenzveig
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ian Persits
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ahmad Gharaibeh
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Ashwin Kumar
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell, and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Ankit Agrawal
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell, and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lidiya Sul
- Department of Internal Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Nicholas Chan
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Tom Kai Ming Wang
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell, and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Mazen Hanna
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell, and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Allan L Klein
- Center for the Diagnosis and Treatment of Pericardial Diseases, Section of Cardiovascular Imaging, Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell, and Arnold Miller Family Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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Cotella J, Randazzo M, Maurer MS, Helmke S, Scherrer-Crosbie M, Soltani M, Goyal A, Zareba K, Cheng R, Kirkpatrick JN, Yogeswaran V, Kitano T, Takeuchi M, Fernandes F, Hotta VT, Campos Vieira ML, Elissamburu P, Ronderos R, Prado A, Koutroumpakis E, Deswal A, Pursnani A, Sarswat N, Addetia K, Mor-Avi V, Asch FM, Slivnick JA, Lang RM. Limitations of apical sparing pattern in cardiac amyloidosis: a multicentre echocardiographic study. Eur Heart J Cardiovasc Imaging 2024; 25:754-761. [PMID: 38243591 DOI: 10.1093/ehjci/jeae021] [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: 11/22/2023] [Revised: 01/05/2024] [Accepted: 01/09/2024] [Indexed: 01/21/2024] Open
Abstract
AIMS Although impaired left ventricular (LV) global longitudinal strain (GLS) with apical sparing is a feature of cardiac amyloidosis (CA), its diagnostic accuracy has varied across studies. We aimed to determine the ability of apical sparing ratio (ASR) and most common echocardiographic parameters to differentiate patients with confirmed CA from those with clinical and/or echocardiographic suspicion of CA but with this diagnosis ruled out. METHODS AND RESULTS We identified 544 patients with confirmed CA and 200 controls (CTRLs) as defined above (CTRL patients). Measurements from transthoracic echocardiograms were performed using artificial intelligence software (Us2.AI, Singapore) and audited by an experienced echocardiographer. Receiver operating characteristic curve analysis was used to evaluate the diagnostic performance and optimal cut-offs for the differentiation of CA patients from CTRL patients. Additionally, a group of 174 healthy subjects (healthy CTRL) was included to provide insight on how patients and healthy CTRLs differed echocardiographically. LV GLS was more impaired (-13.9 ± 4.6% vs. -15.9 ± 2.7%, P < 0.0005), and ASR was higher (2.4 ± 1.2 vs. 1.7 ± 0.9, P < 0.0005) in the CA group vs. CTRL patients. Relative wall thickness and ASR were the most accurate parameters for differentiating CA from CTRL patients [area under the curve (AUC): 0.77 and 0.74, respectively]. However, even with the optimal cut-off of 1.67, ASR was only 72% sensitive and 66% specific for CA, indicating the presence of apical sparing in 32% of CTRL patients and even in 6% healthy subjects. CONCLUSION Apical sparing did not prove to be a CA-specific biomarker for accurate identification of CA, when compared with clinically similar CTRLs with no CA.
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Affiliation(s)
- Juan Cotella
- University of Chicago, 5758 S. Maryland Avenue, MC 9067, DCAM 5509, Chicago, IL 60637, USA
| | - Michael Randazzo
- University of Chicago, 5758 S. Maryland Avenue, MC 9067, DCAM 5509, Chicago, IL 60637, USA
| | | | | | | | | | | | | | | | | | | | - Tetsuji Kitano
- University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Masaaki Takeuchi
- University of Occupational and Environmental Health, Kitakyushu, Japan
| | - Fábio Fernandes
- Heart Institute (InCor), São Paulo University Medical School, São Paulo, Brazil
| | - Viviane Tiemi Hotta
- Heart Institute (InCor), São Paulo University Medical School, São Paulo, Brazil
| | | | | | | | - Aldo Prado
- Centro Privado de Cardiología, Tucuman, Argentina
| | | | - Anita Deswal
- University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Amit Pursnani
- NorthShore University Health System, Evanston, IL, USA
| | | | - Karima Addetia
- University of Chicago, 5758 S. Maryland Avenue, MC 9067, DCAM 5509, Chicago, IL 60637, USA
| | - Victor Mor-Avi
- University of Chicago, 5758 S. Maryland Avenue, MC 9067, DCAM 5509, Chicago, IL 60637, USA
| | | | - Jeremy A Slivnick
- University of Chicago, 5758 S. Maryland Avenue, MC 9067, DCAM 5509, Chicago, IL 60637, USA
| | - Roberto M Lang
- University of Chicago, 5758 S. Maryland Avenue, MC 9067, DCAM 5509, Chicago, IL 60637, USA
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Porcari A, Fontana M, Canepa M, Biagini E, Cappelli F, Gagliardi C, Longhi S, Pagura L, Tini G, Dore F, Bonfiglioli R, Bauckneht M, Miceli A, Girardi F, Martini AL, Barbati G, Costanzo EN, Caponetti AG, Paccagnella A, Sguazzotti M, La Malfa G, Zampieri M, Sciagrà R, Perfetto F, Rowczenio D, Gilbertson J, Hutt DF, Hawkins PN, Rapezzi C, Merlo M, Sinagra G, Gillmore JD. Clinical and Prognostic Implications of Right Ventricular Uptake on Bone Scintigraphy in Transthyretin Amyloid Cardiomyopathy. Circulation 2024; 149:1157-1168. [PMID: 38328945 PMCID: PMC11000629 DOI: 10.1161/circulationaha.123.066524] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Accepted: 01/16/2024] [Indexed: 02/09/2024]
Abstract
BACKGROUND The extent of myocardial bone tracer uptake with technetium pyrophosphate, hydroxymethylene diphosphonate, and 3,3-diphosphono-1,2-propanodicarboxylate in transthyretin amyloid cardiomyopathy (ATTR-CM) might reflect cardiac amyloid burden and be associated with outcome. METHODS Consecutive patients with ATTR-CM who underwent diagnostic bone tracer scintigraphy with acquisition of whole-body planar and cardiac single-photon emission computed tomography (SPECT) images from the National Amyloidosis Centre and 4 Italian centers were included. Cardiac uptake was defined according to the Perugini classification: 0=absent cardiac uptake; 1=mild uptake less than bone; 2=moderate uptake equal to bone; and 3=high uptake greater than bone. Extent of right ventricular (RV) uptake was defined as focal (basal segment of the RV free wall only) or diffuse (extending beyond basal segment) on the basis of SPECT imaging. The primary outcome was all-cause mortality. RESULTS Among 1422 patients with ATTR-CM, RV uptake accompanying left ventricular uptake was identified by SPECT imaging in 100% of cases at diagnosis. Median follow-up in the whole cohort was 34 months (interquartile range, 21 to 50 months), and 494 patients died. By Kaplan-Meier analysis, diffuse RV uptake on SPECT imaging (n=936) was associated with higher all-cause mortality compared with focal (n=486) RV uptake (77.9% versus 22.1%; P<0.001), whereas Perugini grade was not associated with survival (P=0.27 in grade 2 versus grade 3). On multivariable analysis, after adjustment for age at diagnosis (hazard ratio [HR], 1.03 [95% CI, 1.02-1.04]; P<0.001), presence of the p.(V142I) TTR variant (HR, 1.42 [95% CI, 1.20-1.81]; P=0.004), National Amyloidosis Centre stage (each category, P<0.001), stroke volume index (HR, 0.99 [95% CI, 0.97-0.99]; P=0.043), E/e' (HR, 1.02 [95% CI, 1.007-1.03]; P=0.004), right atrial area index (HR, 1.05 [95% CI, 1.02-1.08]; P=0.001), and left ventricular global longitudinal strain (HR, 1.06 [95% CI, 1.03-1.09]; P<0.001), diffuse RV uptake on SPECT imaging (HR, 1.60 [95% CI, 1.26-2.04]; P<0.001) remained an independent predictor of all-cause mortality. The prognostic value of diffuse RV uptake was maintained across each National Amyloidosis Centre stage and in both wild-type and hereditary ATTR-CM (P<0.001 and P=0.02, respectively). CONCLUSIONS Diffuse RV uptake of bone tracer on SPECT imaging is associated with poor outcomes in patients with ATTR-CM and is an independent prognostic marker at diagnosis.
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Affiliation(s)
- Aldostefano Porcari
- National Amyloidosis Centre, Division of Medicine, University College London, UK (A.P., M.F., D.R., J.G., D.F.H., P.N.H., J.D.G.)
- Centre for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina and University of Trieste, Italy (A.P., L.P., M.M., G.S.)
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart (A.P., E.B., C.G., S.L., L.P., A.G.C., M.S., M.M., G.S.)
| | - Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, University College London, UK (A.P., M.F., D.R., J.G., D.F.H., P.N.H., J.D.G.)
- Centre for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina and University of Trieste, Italy (A.P., L.P., M.M., G.S.)
| | - Marco Canepa
- Cardiovascular Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy (M.C., G.L.M.)
- Department of Internal Medicine, University of Genova, Italy (M.C.)
| | - Elena Biagini
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart (A.P., E.B., C.G., S.L., L.P., A.G.C., M.S., M.M., G.S.)
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy (E.B., C.G., S.L.)
| | - Francesco Cappelli
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy (F.C., F.P.)
- Cardiomyopathy Unit, Careggi University Hospital, University of Florence, Italy (F.C., M.Z.)
- Department of Nuclear Medicine, Azienda Sanitaria Universitaria Giuliano-Isontina and University of Trieste, Italy (F.D., F.G.)
| | - Christian Gagliardi
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart (A.P., E.B., C.G., S.L., L.P., A.G.C., M.S., M.M., G.S.)
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy (E.B., C.G., S.L.)
| | - Simone Longhi
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart (A.P., E.B., C.G., S.L., L.P., A.G.C., M.S., M.M., G.S.)
- Cardiology Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy (E.B., C.G., S.L.)
| | - Linda Pagura
- Centre for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina and University of Trieste, Italy (A.P., L.P., M.M., G.S.)
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart (A.P., E.B., C.G., S.L., L.P., A.G.C., M.S., M.M., G.S.)
| | - Giacomo Tini
- Department of Clinical and Molecular Medicine, Sapienza University of Rome, Azienda Ospedaliera Universitaria Sant’Andrea, Italy (G.T.)
| | - Franca Dore
- Department of Nuclear Medicine, Azienda Sanitaria Universitaria Giuliano-Isontina and University of Trieste, Italy (F.D., F.G.)
| | - Rachele Bonfiglioli
- Department of Nuclear Medicine, IRCCS, University Sant’Orsola Hospital, University of Bologna, Italy (R.B., A.P.)
| | - Matteo Bauckneht
- Nuclear Medicine, IRCCS Ospedale Policlinico San Martino, Genova, Italy (M.B.)
- Nuclear Medicine, Department of Health Sciences (DISSAL), University of Genova, Italy (M.B.)
| | - Alberto Miceli
- Nuclear Medicine Unit, Azienda Ospedaliera SS. Antonio e Biagio e Cesare Arrigo, Alessandria, Italy (A.M.)
| | - Francesca Girardi
- Department of Nuclear Medicine, Azienda Sanitaria Universitaria Giuliano-Isontina and University of Trieste, Italy (F.D., F.G.)
| | - Anna Lisa Martini
- Nuclear Medicine Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio,” University of Florence, Careggi University Hospital, Italy (A.L.M., E.N.C., R.S.)
| | - Giulia Barbati
- Department of Medical Sciences, Biostatistics Unit, University of Trieste, Italy (G.B.)
| | - Egidio Natalino Costanzo
- Nuclear Medicine Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio,” University of Florence, Careggi University Hospital, Italy (A.L.M., E.N.C., R.S.)
| | - Angelo Giuseppe Caponetti
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy (A.G.C., M.S.)
| | - Andrea Paccagnella
- Department of Nuclear Medicine, IRCCS, University Sant’Orsola Hospital, University of Bologna, Italy (R.B., A.P.)
| | - Maurizio Sguazzotti
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart (A.P., E.B., C.G., S.L., L.P., A.G.C., M.S., M.M., G.S.)
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy (A.G.C., M.S.)
| | - Giovanni La Malfa
- Cardiovascular Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy (M.C., G.L.M.)
| | - Mattia Zampieri
- Cardiomyopathy Unit, Careggi University Hospital, University of Florence, Italy (F.C., M.Z.)
| | - Roberto Sciagrà
- Nuclear Medicine Unit, Department of Experimental and Clinical Biomedical Sciences “Mario Serio,” University of Florence, Careggi University Hospital, Italy (A.L.M., E.N.C., R.S.)
| | - Federico Perfetto
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy (F.C., F.P.)
| | - Dorota Rowczenio
- National Amyloidosis Centre, Division of Medicine, University College London, UK (A.P., M.F., D.R., J.G., D.F.H., P.N.H., J.D.G.)
| | - Janet Gilbertson
- National Amyloidosis Centre, Division of Medicine, University College London, UK (A.P., M.F., D.R., J.G., D.F.H., P.N.H., J.D.G.)
| | - David F. Hutt
- National Amyloidosis Centre, Division of Medicine, University College London, UK (A.P., M.F., D.R., J.G., D.F.H., P.N.H., J.D.G.)
| | - Philip N. Hawkins
- National Amyloidosis Centre, Division of Medicine, University College London, UK (A.P., M.F., D.R., J.G., D.F.H., P.N.H., J.D.G.)
| | - Claudio Rapezzi
- Cardiothoracic Department, University of Ferrara, Italy (C.R.)
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Ravenna, Italy (C.R.)
| | - Marco Merlo
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart (A.P., E.B., C.G., S.L., L.P., A.G.C., M.S., M.M., G.S.)
| | - Gianfranco Sinagra
- Centre for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina and University of Trieste, Italy (A.P., L.P., M.M., G.S.)
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart (A.P., E.B., C.G., S.L., L.P., A.G.C., M.S., M.M., G.S.)
| | - Julian D. Gillmore
- National Amyloidosis Centre, Division of Medicine, University College London, UK (A.P., M.F., D.R., J.G., D.F.H., P.N.H., J.D.G.)
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Aaseth E, Christiansen JR. Prevalence of transthyretin amyloid cardiomyopathy in pacemaker patients. ESC Heart Fail 2024; 11:871-876. [PMID: 38204282 DOI: 10.1002/ehf2.14645] [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: 03/30/2023] [Revised: 11/19/2023] [Accepted: 12/09/2023] [Indexed: 01/12/2024] Open
Abstract
AIMS Transthyretin amyloid cardiomyopathy (ATTR-CM) is characterized by increased wall thickness, diastolic dysfunction and progressive heart failure symptoms. The disease may infiltrate the conduction system leading to conduction disturbances requiring an implantation of permanent cardiac pacemaker (PM), but the extent is unknown. Here, we report the prevalence of ATTR-CM in patients ≥65 years with PM. METHODS AND RESULTS In this prospective, cross-sectional single-centre study patients were recruited from our out-patient pacemaker clinic. Eligibility criteria were age above 65 years, permanent cardiac pacemaker and competent to give informed consent. Patients underwent echocardiography at the pacemaker visit and were referred to 99mTc-DPD-scintigraphy (DPD) and blood samples if septum thickness was ≥12 mm, defined as left ventricular hypertrophy (LVH). Fifty eight of the 128 patients had LVH on echocardiography. Eleven patients had a DPD-scintigraphy based diagnosis of ATTR-CM, which represent 19% of patients with LVH and 9% of the total cohort. Patients diagnosed with ATTR-CM had higher concentrations of cardiac biomarkers (P < 0.001), higher E/E' (P = 0.001), and lower global longitudinal strain (P = 0.003) on echocardiography and more heart failure symptoms (P = 0.001). CONCLUSIONS The prevalence of ATTR-CM in elderly patients with PM and LVH on echocardiography was 19%.
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Affiliation(s)
- Eirik Aaseth
- Department of Medicine, Innlandet Hospital Trust, Elverum, Norway
- Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway
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Karameh M, Meir K, Qadan A, Pappo O, Cohen D, Durst R, Amir O, Asleh R. Endomyocardial biopsy in clinical practice: the diagnostic yield and insights from a 5-year single-center experience. Hellenic J Cardiol 2024:S1109-9666(24)00059-9. [PMID: 38479703 DOI: 10.1016/j.hjc.2024.03.004] [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: 11/18/2023] [Revised: 01/09/2024] [Accepted: 03/03/2024] [Indexed: 05/16/2024] Open
Abstract
OBJECTIVES Endomyocardial biopsy (EMB) is a diagnostic tool for evaluating various cardiac conditions, such as myocarditis and myocardial infiltrative diseases. It is also the gold standard screening technique for detecting allograft rejection after heart transplantation. Despite advances in noninvasive imaging modalities for myocardial tissue characterization, EMB is still necessary for making a definitive diagnosis and determining treatment for certain conditions. Herein, we report our recent experience using EMB and its diagnostic yield. METHODS AND RESULTS We retrospectively reviewed EMBs performed at our institution from March 2018 through March 2023. Clinical data, including patient characteristics, indication and diagnostic yield of EMB, and procedure-related complications, were collected. Histopathological findings of the biopsies were recorded and classified based on the degree to which they matched the clinical diagnosis and cardiac magnetic resonance imaging (CMR) findings. A total of 212 EMBs obtained in 178 consecutive patients were retrospectively analyzed, with 42 biopsies performed for allograft rejection surveillance (10 patients) and the remaining performed for presumptive diagnosis of acute myocarditis or unexplained cardiomyopathy. Among the non-heart transplant cases, 54.7% of EMBs provided a clear diagnosis. The most common diagnosis was myocarditis (69%), followed by cardiac amyloidosis (CA) (26%). EMB was also helpful in detecting several rare cardiac conditions, such as eosinophilic granulomatosis with polyangiitis (EGPA), Fabry disease, and cardiac sarcoidosis. In a cohort of 101 patients who underwent both CMR and EMB, the results were concordant in 66% of cases. However, in 24.7% of patients, EMB was able to identify pathological conditions where CMR results were inconclusive, highlighting its complementary role in determining an accurate diagnosis. No complications were reported in any of the 212 EMBs performed. CONCLUSIONS With advances in cardiac imaging modalities, EMB is not routinely indicated for the diagnosis of cardiomyopathy. However, EMB is still an important tool for diagnosing specific cardiac diseases and could be crucial for confirming the diagnosis. EMB is generally safe if performed at experienced centers.
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Affiliation(s)
- Mutaz Karameh
- Heart Institute, Hadassah University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Karen Meir
- Department of Pathology, Hadassah University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Abed Qadan
- Heart Institute, Hadassah University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Orit Pappo
- Department of Pathology, Hadassah University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Dotan Cohen
- Department of Radiology, Hadassah University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ronen Durst
- Heart Institute, Hadassah University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Offer Amir
- Heart Institute, Hadassah University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Rabea Asleh
- Heart Institute, Hadassah University Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
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Ungericht M, Groaz V, Messner M, Schuetz T, Brunelli L, Zaruba MM, Lener D, Stocker E, Bauer A, Kroiss AS, Mayr A, Röcken C, Poelzl G. Correlation of 99mTc-DPD bone scintigraphy with histological amyloid load in patients with ATTR cardiac amyloidosis. Amyloid 2024; 31:22-31. [PMID: 37530216 DOI: 10.1080/13506129.2023.2239986] [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: 02/26/2023] [Accepted: 07/18/2023] [Indexed: 08/03/2023]
Abstract
BACKGROUND The significance of measuring 99mTc-labelled-3,3-diphosphono-1,2-propanodicarboxylic acid (99mTc-DPD) in transthyretin (ATTR) cardiac amyloidosis has not been adequately studied. This single-centre observational study evaluated the correlation between 99mTc-DPD scintigraphy and histological amyloid load in endomyocardial biopsy (EMB). METHODS Twenty-eight patients with biopsy-proven ATTR amyloidosis and concomitantly available 99mTc-DPD scintigraphy were included. Visual Perugini scoring, and (semi-)quantitative analysis of cardiac 99mTc-DPD uptake by planar whole-body imaging and single photon emission computed tomography (SPECT/CT) using regions of interest (ROI) were performed. From this, heart-to-whole-body ratio (H/WB) and heart-to-contralateral-chest ratio (H/CL) were calculated. The histological amyloid load was quantified using two different staining methods. RESULTS Increased cardiac tracer uptake was documented in all patients (planar: ROImean 129 ± 37 cps; SPECT/CT: ROImean 369 ± 142 cps). Histological amyloid load (19 ± 13%) significantly correlated with Perugini score (r = 0.69, p < .001) as well as with cardiac 99mTc-DPD uptake (planar: r = 0.64, p < .001; H/WB: r = 0.50, p = .014; SPECT/CT: r = 0.53, p = .008; H/CL: r = 0.43, p = .037) (results are shown for correlations with Congo Red-staining). CONCLUSION In ATTR, cardiac 99mTc-DPD uptake significantly correlated with histological amyloid load in EMB. Further studies are needed to implement thresholds in cardiac 99mTc-DPD uptake measurements for risk stratification and guidance of therapy.
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Affiliation(s)
- Maria Ungericht
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Valeria Groaz
- Department of Emergency Medicine, Klinik Arlesheim, Arlesheim, Switzerland
| | - Moritz Messner
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Thomas Schuetz
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Luca Brunelli
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Marc-Michael Zaruba
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Daniela Lener
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Eva Stocker
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Axel Bauer
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
| | | | - Agnes Mayr
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Christoph Röcken
- Department of Pathology, Christian-Albrechts-University, Kiel, Germany
| | - Gerhard Poelzl
- Department of Internal Medicine III, Cardiology and Angiology, Medical University of Innsbruck, Innsbruck, Austria
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Azevedo Coutinho MC, Cortez-Dias N, Cantinho G, Gonçalves S, Cunha N, Rodrigues T, Santos L, Conceição I, Agostinho J, Pinto FJ. Diagnostic and prognostic contribution of DPD scintigraphy in transthyretin V30M cardiac amyloidosis. Amyloid 2024; 31:32-41. [PMID: 37493395 DOI: 10.1080/13506129.2023.2239987] [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: 01/20/2023] [Accepted: 07/18/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Early diagnosis and prognostic stratification of cardiac transthyretin amyloidosis are crucial. Although 99mTc 3,3-diphosphono-1,2-propanedicarboxylic acid (DPD) scintigraphy is the preferred method for the non-invasive diagnosis, its accuracy appears to be limited in transthyretin amyloidosis protein (ATTR) V30M mutation. Furthermore, its prognostic value in this mutation is unknown. This study investigated the diagnostic value of DPD scintigraphy to detect ATTR cardiomyopathy in V30M mutation and explored its prognostic value regarding mortality. METHODS A total of 288 ATTR V30M mutation carriers (median age: 46 years; 49% males) without myocardial thickening (defined as septal thickness ≥13mm) attributable to other causes and who underwent DPD scintigraphy were enrolled. ATTR cardiomyopathy was defined by septal thickness ≥13mm and at least one of the criteria: late heart-to-mediastinum (H/M) 123I-metaiodobenzylguanidine (MIBG) uptake ratio <1.60; electrical heart disease or biopsy-documented amyloidosis. RESULTS ATTR cardiomyopathy was identified in 41 (14.2%) patients and cardiac DPD uptake in 34 (11.8%). During a mean follow-up of 33.6 ± 1.2 months, 16 patients died (5.6%). Mortality was 14 times higher in patients with ATTR cardiomyopathy, 13 times higher in those with DPD uptake and 10 times higher in those with late H/M MIBG <1.60. The combined assessment of septal thickness and cardiac DPD uptake improved risk stratification: patients without septal thickening and without DPD retention had an excellent prognosis while those who presented either or both of them had a significantly worse prognosis, with 5-year mortality rates ranging from 39.9 to 53.3%. CONCLUSIONS DPD scintigraphy is useful for prognostic stratification of ATTR V30M mutation carriers. Patients without septal thickening and no DPD uptake present the best prognosis compared to those with any signs of cardiac involvement.
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Affiliation(s)
- Maria C Azevedo Coutinho
- Department of Cardiology, Santa Maria University Hospital, Lisbon Academic Medical Centre and Cardiovascular Centre of the University of Lisbon, Faculty of Medicine, Lisbon, Portugal
- Translational Clinical Physiology Unit, Institute of Molecular Medicine, University of Lisbon, Portugal
| | - Nuno Cortez-Dias
- Department of Cardiology, Santa Maria University Hospital, Lisbon Academic Medical Centre and Cardiovascular Centre of the University of Lisbon, Faculty of Medicine, Lisbon, Portugal
| | - Guilhermina Cantinho
- Institute of Nuclear Medicine, Lisbon Academic Medical Centre, University of Lisbon, Lisbon, Portugal
| | - Susana Gonçalves
- Department of Cardiology, Santa Maria University Hospital, Lisbon Academic Medical Centre and Cardiovascular Centre of the University of Lisbon, Faculty of Medicine, Lisbon, Portugal
| | - Nelson Cunha
- Department of Cardiology, Santa Maria University Hospital, Lisbon Academic Medical Centre and Cardiovascular Centre of the University of Lisbon, Faculty of Medicine, Lisbon, Portugal
| | - Tiago Rodrigues
- Department of Cardiology, Santa Maria University Hospital, Lisbon Academic Medical Centre and Cardiovascular Centre of the University of Lisbon, Faculty of Medicine, Lisbon, Portugal
| | - Laura Santos
- Department of Cardiology, Santa Maria University Hospital, Lisbon Academic Medical Centre and Cardiovascular Centre of the University of Lisbon, Faculty of Medicine, Lisbon, Portugal
| | - Isabel Conceição
- Translational Clinical Physiology Unit, Institute of Molecular Medicine, University of Lisbon, Portugal
- Department of Neurosciences, Santa Maria University Hospital, Lisbon Academic Medical Centre, Portugal
| | - João Agostinho
- Department of Cardiology, Santa Maria University Hospital, Lisbon Academic Medical Centre and Cardiovascular Centre of the University of Lisbon, Faculty of Medicine, Lisbon, Portugal
| | - Fausto J Pinto
- Department of Cardiology, Santa Maria University Hospital, Lisbon Academic Medical Centre and Cardiovascular Centre of the University of Lisbon, Faculty of Medicine, Lisbon, Portugal
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8
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Redzepi B, Kamani CH, Maurizi N, Théaudin M, Prior J, Monney P. False Negative 99mTc-DPD Scintigraphy in pVal50Met (Val30Met) Hereditary Transthyretin Amyloidosis. CJC Open 2024; 6:118-121. [PMID: 38585682 PMCID: PMC10994964 DOI: 10.1016/j.cjco.2023.11.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 11/09/2023] [Indexed: 04/09/2024] Open
Affiliation(s)
- Betim Redzepi
- Department of Cardiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Christel H. Kamani
- Department of Cardiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- Department of Nuclear Medicine and Molecular Imaging, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Niccolo Maurizi
- Department of Cardiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
| | - Marie Théaudin
- Department of Neurology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- University of Lausanne (UNIL), Faculty of Biology and Medicine, Lausanne, Switzerland
| | - John Prior
- Department of Nuclear Medicine and Molecular Imaging, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- University of Lausanne (UNIL), Faculty of Biology and Medicine, Lausanne, Switzerland
| | - Pierre Monney
- Department of Cardiology, Lausanne University Hospital (CHUV), Lausanne, Switzerland
- University of Lausanne (UNIL), Faculty of Biology and Medicine, Lausanne, Switzerland
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9
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Tingen HSA, Berends M, Tubben A, Bijzet J, Houwerzijl EJ, Muntinghe FLH, Kroesen BJ, van der Zwaag PA, van der Meer P, Slart RHJA, Hazenberg BPC, Nienhuis HLA. High-Sensitivity Cardiac Troponin T to Exclude Cardiac Involvement in TTR Variant Carriers and ATTRv Amyloidosis Patients. J Clin Med 2024; 13:810. [PMID: 38337504 PMCID: PMC10856062 DOI: 10.3390/jcm13030810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 01/17/2024] [Accepted: 01/19/2024] [Indexed: 02/12/2024] Open
Abstract
(1) Background: Individuals carrying a pathogenic transthyretin gene variant (TTRv) are at high risk for developing hereditary transthyretin (ATTRv) amyloidosis and are routinely screened for the development of cardiomyopathy (ATTRv-CM). This study aims to evaluate whether the cardiac biomarkers N-terminal pro B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hs-cTnT) can be used to rule out ATTRv-CM. (2) Methods: In this retrospective case-control study, data from 46 ATTRv-CM patients and 101 TTRv carriers and ATTRv amyloidosis patients without cardiomyopathy were included. Binary logistic regression models were used to assess the ability of NT-proBNP and hs-cTnT to predict the diagnosis of ATTRv-CM. An optimal cutoff for the relevant biomarker(s) was determined based on a sensitivity of ≥99% and the highest possible percentage of additional tests avoided (%ATA) in the index dataset. (3) Results: Hs-cTnT demonstrated the highest predictive capabilities for ATTRv-CM. The addition of NT-proBNP did not improve the predictive model. A hs-cTnT cutoff of <6 ng/L resulted in a 97% sensitivity and a negative predictive value of 95% with a %ATA of 30% in the validation dataset. (4) Conclusion: In conclusion, hs-cTnT is a useful biomarker for excluding cardiac involvement in TTRv carriers and ATTRv amyloidosis patients and it has the potential to prevent unnecessary diagnostic procedures.
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Affiliation(s)
- Hendrea S. A. Tingen
- Department of Nuclear Medicine and Molecular Imaging, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Milou Berends
- Department of Internal Medicine, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands (H.L.A.N.)
| | - Alwin Tubben
- Department of Cardiology, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Johan Bijzet
- Department of Laboratory Medicine, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Ewout J. Houwerzijl
- Department of Internal Medicine, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands (H.L.A.N.)
| | - Friso L. H. Muntinghe
- Department of Internal Medicine, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands (H.L.A.N.)
| | - Bart-Jan Kroesen
- Department of Laboratory Medicine, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Paul A. van der Zwaag
- Department of Genetics, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Peter van der Meer
- Department of Cardiology, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Riemer H. J. A. Slart
- Department of Nuclear Medicine and Molecular Imaging, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
- Biomedical Photonic Imaging Group, Faculty of Science and Technology, University of Twente, Drienerlolaan 5, 7522 NB Enschede, The Netherlands
| | - Bouke P. C. Hazenberg
- Department of Rheumatology & Clinical Immunology, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands
| | - Hans L. A. Nienhuis
- Department of Internal Medicine, Groningen Amyloidosis Centre of Expertise, University of Groningen, University Medical Centre Groningen, Hanzeplein 1, 9713 GZ Groningen, The Netherlands (H.L.A.N.)
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10
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Saro R, Pavan D, Porcari A, Sinagra G, Mojoli M. Lights and Shadows of Clinical Applications of Cardiac Scintigraphy with Bone Tracers in Suspected Amyloidosis. J Clin Med 2023; 12:7605. [PMID: 38137674 PMCID: PMC10743682 DOI: 10.3390/jcm12247605] [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: 10/13/2023] [Revised: 11/20/2023] [Accepted: 12/07/2023] [Indexed: 12/24/2023] Open
Abstract
Radionuclide bone scintigraphy is the cornerstone of an imaging-based algorithm for accurate non-invasive diagnosis of transthyretin cardiac amyloidosis (ATTR-CA). In patients with heart failure and suggestive echocardiographic and/or cardiac magnetic resonance imaging findings, the positive predictive value of Perugini grade 2 or 3 myocardial uptake on a radionuclide bone scan approaches 100% for the diagnosis of ATTR-CA as long as there is no biochemical evidence of a clonal dyscrasia. The technetium-labelled tracers that are currently validated for non-invasive diagnosis of ATTR-CA include pyrophosphate (99mTc-PYP); hydroxymethylene diphosphonate (99mTc-HMDP); and 3,3-diphosphono-1,2-propanodicarboxylate (99mTc-DPD). Although nuclear scintigraphy has transformed the contemporary diagnostic approach to ATTR-CA, a number of grey areas remains, including the mechanism for binding tracers to the infiltrated heart, differences in the kinetics and distribution of these radiotracers, differences in protocols of image acquisition worldwide, the clinical significance of extra-cardiac uptake, and the use of this technique for prognostic stratification, monitoring disease progression and assessing the response to disease-modifying treatments. This review will deal with the most relevant unmet needs and clinical questions concerning scintigraphy with bone tracers in ATTR-CA, providing expert opinions on possible future developments in the clinical application of these radiotracers in order to offer practical information for the interpretation of nuclear images by physicians involved in the care of patients with this ATTR-CA.
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Affiliation(s)
- Riccardo Saro
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via P. Valdoni 7, 34100 Trieste, Italy; (R.S.); (A.P.); (G.S.)
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Giuliano Isontina University Health Authority, 34149 Trieste, Italy
| | - Daniela Pavan
- Ospedale Santa Maria degli Angeli, Azienda Ospedaliera Friuli Occidentale (ASFO), 33170 Pordenone, Italy;
| | - Aldostefano Porcari
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via P. Valdoni 7, 34100 Trieste, Italy; (R.S.); (A.P.); (G.S.)
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Giuliano Isontina University Health Authority, 34149 Trieste, Italy
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Gianfranco Sinagra
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Via P. Valdoni 7, 34100 Trieste, Italy; (R.S.); (A.P.); (G.S.)
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Giuliano Isontina University Health Authority, 34149 Trieste, Italy
| | - Marco Mojoli
- Ospedale Santa Maria degli Angeli, Azienda Ospedaliera Friuli Occidentale (ASFO), 33170 Pordenone, Italy;
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11
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Jaiswal V, Agrawal V, Khulbe Y, Hanif M, Huang H, Hameed M, Shrestha AB, Perone F, Parikh C, Gomez SI, Paudel K, Zacks J, Grubb KJ, De Rosa S, Gimelli A. Cardiac amyloidosis and aortic stenosis: a state-of-the-art review. EUROPEAN HEART JOURNAL OPEN 2023; 3:oead106. [PMID: 37941729 PMCID: PMC10630099 DOI: 10.1093/ehjopen/oead106] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 10/03/2023] [Accepted: 10/04/2023] [Indexed: 11/10/2023]
Abstract
Cardiac amyloidosis is caused by the extracellular deposition of amyloid fibrils in the heart, involving not only the myocardium but also any cardiovascular structure. Indeed, this progressive infiltrative disease also involves the cardiac valves and, specifically, shows a high prevalence with aortic stenosis. Misfolded protein infiltration in the aortic valve leads to tissue damage resulting in the onset or worsening of valve stenosis. Transthyretin cardiac amyloidosis and aortic stenosis coexist in patients > 65 years in about 4-16% of cases, especially in those undergoing transcatheter aortic valve replacement. Diagnostic workup for cardiac amyloidosis in patients with aortic stenosis is based on a multi-parametric approach considering clinical assessment, electrocardiogram, haematologic tests, basic and advanced echocardiography, cardiac magnetic resonance, and technetium labelled cardiac scintigraphy like technetium-99 m (99mTc)-pyrophosphate, 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid, and 99mTc-hydroxymethylene diphosphonate. However, a biopsy is the traditional gold standard for diagnosis. The prognosis of patients with coexisting cardiac amyloidosis and aortic stenosis is still under evaluation. The combination of these two pathologies worsens the prognosis. Regarding treatment, mortality is reduced in patients with cardiac amyloidosis and severe aortic stenosis after undergoing transcatheter aortic valve replacement. Further studies are needed to confirm these findings and to understand whether the diagnosis of cardiac amyloidosis could affect therapeutic strategies. The aim of this review is to critically expose the current state-of-art regarding the association of cardiac amyloidosis with aortic stenosis, from pathophysiology to treatment.
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Affiliation(s)
- Vikash Jaiswal
- Department of Cardiovascular Research, Larkin Community Hospital, South Miami, FL, USA
| | - Vibhor Agrawal
- Department of Medicine, King George’s Medical University, Lucknow, India
| | - Yashita Khulbe
- Department of Medicine, King George’s Medical University, Lucknow, India
| | - Muhammad Hanif
- Department of Internal Medicine, SUNY Upstate Medical University, Syracuse, NY, USA
| | - Helen Huang
- University of Medicine and Health Science, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Maha Hameed
- Department of Internal Medicine, Florida State University, Sarasota Memorial Hospital, Sarasota, FL, USA
| | - Abhigan Babu Shrestha
- Department of Internal Medicine, M Abdur Rahim Medical College, Dinajpur, Bangladesh
| | - Francesco Perone
- Cardiac Rehabilitation Unit, Rehabilitation Clinic ‘Villa delle Magnolie’,81020 Castel Morrone, Caserta, Italy
| | | | - Sabas Ivan Gomez
- Department of Cardiovascular Research, Larkin Community Hospital, South Miami, FL, USA
| | - Kusum Paudel
- Department of Medicine, Kathmandu University School of Medical Science, Dhulikhel, Kathmandu 45209, Nepal
| | - Jerome Zacks
- Department of Cardiology, The Icahn Medical School at Mount Sinai, NewYork 10128, USA
| | - Kendra J Grubb
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University School of Medicine, Atlanta, GA, USA
| | - Salvatore De Rosa
- Department of Medical and Surgical Sciences, Magna Graecia University, Catanzaro, Italy
| | - Alessia Gimelli
- Department of Imaging, Fondazione Toscana/CNR Gabriele Monasterio, Pisa 56124, Italy
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12
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Lee Y, Jang J, Na SJ. Diffuse Cardiac Uptake Misdiagnosed as Cardiac Amyloidosis in Bone Scan. Diagnostics (Basel) 2023; 13:3342. [PMID: 37958238 PMCID: PMC10647204 DOI: 10.3390/diagnostics13213342] [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: 10/11/2023] [Revised: 10/25/2023] [Accepted: 10/27/2023] [Indexed: 11/15/2023] Open
Abstract
In this presented case, a 77-year-old woman with an implanted prosthesis and ongoing knee pain underwent a bone scan using 99mTc-hydroxydiphosphonate (HDP) in suspicion for bone infection. An incidental finding from this scan revealed diffuse cardiac uptake, necessitating further diagnostic procedures to exclude the possibility of cardiac amyloidosis. In the subsequent 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) scan and SPECT images, no perceptible cardiac uptake was observed at all. Upon retrospective review of the patient's medical records, she received 1000 mg of ferric carboxymaltose for iron-deficient anemia the day before the 99mTc-HDP bone scan. Therefore, it was assumed that the diffuse and temporary cardiac activity was due to the transient iron overload. We present and share these bone scan images in order to avoid possible future misinterpretation of cardiac amyloidosis.
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Affiliation(s)
- Yeongjoo Lee
- Department of Radiology, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea;
| | - Jaehyuk Jang
- Division of Cardiology, Department of Internal Medicine, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea;
| | - Sae Jung Na
- Department of Radiology, Uijeongbu St. Mary’s Hospital, College of Medicine, The Catholic University of Korea, Seoul 06591, Republic of Korea;
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13
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Tana M, Tana C, Palmiero G, Mantini C, Coppola MG, Limongelli G, Schiavone C, Porreca E. Imaging findings of right cardiac amyloidosis: impact on prognosis and clinical course. J Ultrasound 2023; 26:605-614. [PMID: 37162729 PMCID: PMC10171176 DOI: 10.1007/s40477-023-00789-1] [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: 10/14/2022] [Accepted: 04/04/2023] [Indexed: 05/11/2023] Open
Abstract
Cardiac involvement from amyloidosis is of growing interest in the overall literature. Despite cardiac amyloidosis (CA) has been considered for a long time a rare disease, the diagnostic awareness is increasing mainly thanks to the improvement of diagnostic softwares and of imaging techniques such as cardiac magnetic resonance (CMR). Some authors have observed an increase of prevalence rate of CA; moreover it's often underestimated because clinical manifestations are aspecific. The interstitial infiltration of the left ventricle has been extensively studied, while the involvement of the right ventricle (RV) has been less investigated. Involvement of the RV, even in the absence of pulmonary hypertension or clearly left ventricle infiltration, plays an important role as prognostic factor and is useful to achieve an early diagnosis. Therefore, the use of fast and low-cost diagnostic methods such as ultrasound strain of the right ventricle could be used to recognize cardiac amyloidosis early. Herein the importance of evaluating the right ventricular involvement, which can predict the most severe course of the disease also without overt clinical manifestations. The role of imaging, in particular of echocardiography, CMR, and scintigraphy is here reported.
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Affiliation(s)
- Marco Tana
- Internal Medicine Unit, Medical Department, SS. Annunziata Hospital of Chieti, Via Dei Vestini 31, 66100, Chieti, Italy.
- Cardiovascular Ultrasound Department, SS. Annunziata Hospital, Chieti, Italy.
- Department of Medical, Oral and Biotechnological Sciences, "G. D'Annunzio" University of Chieti-Pescara, Chieti, Italy.
| | - Claudio Tana
- COVID-19 Medicine Unit and Geriatrics Clinic, Medical Department, SS. Annunziata Hospital, Chieti, Italy
| | - Giuseppe Palmiero
- Rare Cardiac Disease Unit, Department of Translational Medical Sciences, "Luigi Vanvitelli" University, Naples, Italy
| | - Cesare Mantini
- Department of Neuroscience, Imaging and Clinical Sciences, "G. d'Annunzio" University of Chieti-Pescara, Chieti, Italy
| | | | - Giuseppe Limongelli
- Rare Cardiac Disease Unit, Department of Translational Medical Sciences, "Luigi Vanvitelli" University, Naples, Italy
| | | | - Ettore Porreca
- Internal Medicine Unit, Medical Department, SS. Annunziata Hospital of Chieti, Via Dei Vestini 31, 66100, Chieti, Italy
- Cardiovascular Ultrasound Department, SS. Annunziata Hospital, Chieti, Italy
- Department of Medical, Oral and Biotechnological Sciences, "G. D'Annunzio" University of Chieti-Pescara, Chieti, Italy
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14
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Meier C, Yilmaz A. [Diagnostics of cardiac amyloidosis]. INNERE MEDIZIN (HEIDELBERG, GERMANY) 2023; 64:830-841. [PMID: 37553542 DOI: 10.1007/s00108-023-01571-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 07/17/2023] [Indexed: 08/10/2023]
Abstract
The early diagnosis of cardiac amyloidosis is decisive for the success of treatment of affected persons. The thorough clinical investigation of the patient should be followed by appropriate diagnostics using modern procedures. The main symptoms are dyspnea, loss of performance and edema and in later stages cardiac arrhythmias in the form of atrioventricular conduction disturbances and atrial fibrillation but ventricular arrhythmias occur more rarely. During heart failure due to cardiac amyloidosis an increase of cardiac enzymes frequently occurs (e.g., creatine kinase, troponin, N‑terminal pro-brain natriuretic peptide), which can be included in the risk stratification and treatment monitoring, taking certain limitations into consideration. The investigation of light chains in serum and/or urine should be carried out immediately, as soon as there is a clinical and echocardiographic suspicion of cardiac amyloidosis. Subsequently, either cardiac magnetic resonance imaging (MRI) or bone scintigraphy should be carried out, depending on the locally available options. Depending on the results of these two imaging procedures, a decision must be made as to whether further diagnostic steps (e.g., endomyocardial biopsy) are necessary. In the last decade bone scintigraphy has proven to be a blessing for the diagnostics of cardiac amyloidosis but many partial aspects and limitations necessitate special and careful consideration. A Perugini score of 2 or 3 is initially "indicative" of cardiac amyloidosis but not yet "confirmative" for a specific subtype. Only after an additional negative result of the light chain determination, can the diagnosis of ATTR amyloidosis be noninvasively made. Cardiac amyloidosis shows a particularly characteristic contrast enhancement in cardiac MRI, which mostly begins in the inner (subendocardial) layers of the basal left ventricular (LV) wall and frequently appears to be circular in the cross-sectional view of the left ventricle. Supplementary T1 and extracellular volume fraction mapping results, which are shown as color-coded maps, enable the rapid and elegant assessment of the myocardial structure and the extent of amyloid deposition. An additional investigation of the TTR gene is recommended in the case of ATTR amyloidosis for a differentiation between hereditary and acquired ATTR, as from this, further therapeutic consequences can be derived.
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Affiliation(s)
- Claudia Meier
- Sektion für Herzbildgebung/Klinik für Kardiologie I, Universitätsklinikum Münster, Von-Esmarch-Str. 48, 48149, Münster, Deutschland
| | - Ali Yilmaz
- Sektion für Herzbildgebung/Klinik für Kardiologie I, Universitätsklinikum Münster, Von-Esmarch-Str. 48, 48149, Münster, Deutschland.
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15
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Wollenweber T, Rettl R, Kretschmer-Chott E, Rasul S, Kulterer OC, Kluge K, Duca F, Bonderman D, Hacker M, Traub-Weidinger T. Cardiac DPD-uptake time dependency in ATTR patients verified by quantitative SPECT/CT and semiquantitative planar parameters. J Nucl Cardiol 2023; 30:1363-1371. [PMID: 36513919 PMCID: PMC10371940 DOI: 10.1007/s12350-022-03149-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2022] [Accepted: 10/18/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Bone scintigraphy plays an important role in the diagnosis of cardiac Transthyretin-Related Amyloidosis (ATTR). The mechanism of myocardial tracer accumulation and its dependence over time are not fully understood. Recently, a scintigraphic quantification of the cardiac amyloid deposition has been discussed. Nevertheless, little is known regarding the right time of quantitative imaging. METHODS The geometrical mean of decay corrected total counts over the heart and the heart/whole-body ratio (H/WB) were evaluated in 23 patients undergoing DPD-bone scan with planar whole-body images 1 and 3 hours post injection (p.i.). Myocardial standard uptake values (SUV)peak were assessed in another 15 patients with quantitative SPECT/CT imaging 1 hours and 3 hours p.i.. RESULTS Total counts over the heart (1 hours p.i.: 81,676 cts, range 69,887 to 93,091 cts and 3 hours p.i.: 64,819 cts, range 52,048 to 86,123 cts, P = .0005) and H/WB ratio (1 hours p.i.:0.076 ± 0.020 and 3 hours p.i. 0.070 ± 0.022; P = .0003) were significantly increased 1 hours p.i.. Furthermore median myocardial SUVpeak (1 hours p.i.:12.2, range 9.6 to 18.9 and 3 hours p.i.: 9.6, range 8.2 to 15.0, P = 0.0012) was also significantly higher after 1 hours p.i. compared to 3 hours p.i.. CONCLUSION Cardiac DPD activity and myocardial SUVpeak are time-dependent, which should be considered when using quantitative bone scintigraphy in ATTR patients.
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Affiliation(s)
- Tim Wollenweber
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Rene Rettl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Elisabeth Kretschmer-Chott
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Sazan Rasul
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Oana Cristina Kulterer
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Kilian Kluge
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Franz Duca
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Diana Bonderman
- 5th Medical Department with Cardiology, Clinic Favoriten, Vienna, Austria
| | - Marcus Hacker
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Tatjana Traub-Weidinger
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria.
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Garcia-Pavia P, Aus dem Siepen F, Donal E, Lairez O, van der Meer P, Kristen AV, Mercuri MF, Michalon A, Frost RJA, Grimm J, Nitsch RM, Hock C, Kahr PC, Damy T. Phase 1 Trial of Antibody NI006 for Depletion of Cardiac Transthyretin Amyloid. N Engl J Med 2023; 389:239-250. [PMID: 37212440 DOI: 10.1056/nejmoa2303765] [Citation(s) in RCA: 56] [Impact Index Per Article: 56.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
BACKGROUND Transthyretin amyloid (ATTR) cardiomyopathy is a progressive and fatal disease caused by misfolded transthyretin. Despite advances in slowing disease progression, there is no available treatment that depletes ATTR from the heart for the amelioration of cardiac dysfunction. NI006 is a recombinant human anti-ATTR antibody that was developed for the removal of ATTR by phagocytic immune cells. METHODS In this phase 1, double-blind trial, we randomly assigned (in a 2:1 ratio) 40 patients with wild-type or variant ATTR cardiomyopathy and chronic heart failure to receive intravenous infusions of either NI006 or placebo every 4 weeks for 4 months. Patients were sequentially enrolled in six cohorts that received ascending doses (ranging from 0.3 to 60 mg per kilogram of body weight). After four infusions, patients were enrolled in an open-label extension phase in which they received eight infusions of NI006 with stepwise increases in the dose. The safety and pharmacokinetic profiles of NI006 were assessed, and cardiac imaging studies were performed. RESULTS The use of NI006 was associated with no apparent drug-related serious adverse events. The pharmacokinetic profile of NI006 was consistent with that of an IgG antibody, and no antidrug antibodies were detected. At doses of at least 10 mg per kilogram, cardiac tracer uptake on scintigraphy and extracellular volume on cardiac magnetic resonance imaging, both of which are imaging-based surrogate markers of cardiac amyloid load, appeared to be reduced over a period of 12 months. The median N-terminal pro-B-type natriuretic peptide and troponin T levels also seemed to be reduced. CONCLUSIONS In this phase 1 trial of the recombinant human antibody NI006 for the treatment of patients with ATTR cardiomyopathy and heart failure, the use of NI006 was associated with no apparent drug-related serious adverse events. (Funded by Neurimmune; NI006-101 ClinicalTrials.gov number, NCT04360434.).
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Affiliation(s)
- Pablo Garcia-Pavia
- From Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, CIBERCV, and Centro Nacional de Investigaciones Cardiovasculares, Madrid, and Universidad Francisco de Vitoria, Pozuelo de Alarcón - all in Spain (P.G.-P.); the Department of Cardiology, University Hospital Heidelberg, Heidelberg (F.S.), and Cardiovascular Center Darmstadt, Darmstadt (A.V.K.) - both in Germany; the Department of Cardiology, University of Rennes, Centre Hospitalier Universitaire (CHU) de Rennes, INSERM, LTSI-UMR 1099, Rennes (E.D.), Service de Cardiologie, CHU de Toulouse-Hôpital Rangueil, Toulouse (O.L.), and the Cardiology Department and French National Reference Center for Cardiac Amyloidosis, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, and Institut Mondor de Recherche Biomédicale, INSERM, Université Paris Est Créteil, Créteil (T.D.) - all in France; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); Alexion-AstraZeneca Rare Disease, Boston (M.F.M.); and Neurimmune (A.M., R.J.A.F., J.G., R.M.N., C.H., P.C.K.) and the Institute for Regenerative Medicine (R.M.N., C.H.) and the Center for Molecular Cardiology (P.C.K.), University of Zurich - all in Schlieren, Switzerland
| | - Fabian Aus dem Siepen
- From Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, CIBERCV, and Centro Nacional de Investigaciones Cardiovasculares, Madrid, and Universidad Francisco de Vitoria, Pozuelo de Alarcón - all in Spain (P.G.-P.); the Department of Cardiology, University Hospital Heidelberg, Heidelberg (F.S.), and Cardiovascular Center Darmstadt, Darmstadt (A.V.K.) - both in Germany; the Department of Cardiology, University of Rennes, Centre Hospitalier Universitaire (CHU) de Rennes, INSERM, LTSI-UMR 1099, Rennes (E.D.), Service de Cardiologie, CHU de Toulouse-Hôpital Rangueil, Toulouse (O.L.), and the Cardiology Department and French National Reference Center for Cardiac Amyloidosis, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, and Institut Mondor de Recherche Biomédicale, INSERM, Université Paris Est Créteil, Créteil (T.D.) - all in France; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); Alexion-AstraZeneca Rare Disease, Boston (M.F.M.); and Neurimmune (A.M., R.J.A.F., J.G., R.M.N., C.H., P.C.K.) and the Institute for Regenerative Medicine (R.M.N., C.H.) and the Center for Molecular Cardiology (P.C.K.), University of Zurich - all in Schlieren, Switzerland
| | - Erwan Donal
- From Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, CIBERCV, and Centro Nacional de Investigaciones Cardiovasculares, Madrid, and Universidad Francisco de Vitoria, Pozuelo de Alarcón - all in Spain (P.G.-P.); the Department of Cardiology, University Hospital Heidelberg, Heidelberg (F.S.), and Cardiovascular Center Darmstadt, Darmstadt (A.V.K.) - both in Germany; the Department of Cardiology, University of Rennes, Centre Hospitalier Universitaire (CHU) de Rennes, INSERM, LTSI-UMR 1099, Rennes (E.D.), Service de Cardiologie, CHU de Toulouse-Hôpital Rangueil, Toulouse (O.L.), and the Cardiology Department and French National Reference Center for Cardiac Amyloidosis, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, and Institut Mondor de Recherche Biomédicale, INSERM, Université Paris Est Créteil, Créteil (T.D.) - all in France; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); Alexion-AstraZeneca Rare Disease, Boston (M.F.M.); and Neurimmune (A.M., R.J.A.F., J.G., R.M.N., C.H., P.C.K.) and the Institute for Regenerative Medicine (R.M.N., C.H.) and the Center for Molecular Cardiology (P.C.K.), University of Zurich - all in Schlieren, Switzerland
| | - Olivier Lairez
- From Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, CIBERCV, and Centro Nacional de Investigaciones Cardiovasculares, Madrid, and Universidad Francisco de Vitoria, Pozuelo de Alarcón - all in Spain (P.G.-P.); the Department of Cardiology, University Hospital Heidelberg, Heidelberg (F.S.), and Cardiovascular Center Darmstadt, Darmstadt (A.V.K.) - both in Germany; the Department of Cardiology, University of Rennes, Centre Hospitalier Universitaire (CHU) de Rennes, INSERM, LTSI-UMR 1099, Rennes (E.D.), Service de Cardiologie, CHU de Toulouse-Hôpital Rangueil, Toulouse (O.L.), and the Cardiology Department and French National Reference Center for Cardiac Amyloidosis, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, and Institut Mondor de Recherche Biomédicale, INSERM, Université Paris Est Créteil, Créteil (T.D.) - all in France; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); Alexion-AstraZeneca Rare Disease, Boston (M.F.M.); and Neurimmune (A.M., R.J.A.F., J.G., R.M.N., C.H., P.C.K.) and the Institute for Regenerative Medicine (R.M.N., C.H.) and the Center for Molecular Cardiology (P.C.K.), University of Zurich - all in Schlieren, Switzerland
| | - Peter van der Meer
- From Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, CIBERCV, and Centro Nacional de Investigaciones Cardiovasculares, Madrid, and Universidad Francisco de Vitoria, Pozuelo de Alarcón - all in Spain (P.G.-P.); the Department of Cardiology, University Hospital Heidelberg, Heidelberg (F.S.), and Cardiovascular Center Darmstadt, Darmstadt (A.V.K.) - both in Germany; the Department of Cardiology, University of Rennes, Centre Hospitalier Universitaire (CHU) de Rennes, INSERM, LTSI-UMR 1099, Rennes (E.D.), Service de Cardiologie, CHU de Toulouse-Hôpital Rangueil, Toulouse (O.L.), and the Cardiology Department and French National Reference Center for Cardiac Amyloidosis, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, and Institut Mondor de Recherche Biomédicale, INSERM, Université Paris Est Créteil, Créteil (T.D.) - all in France; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); Alexion-AstraZeneca Rare Disease, Boston (M.F.M.); and Neurimmune (A.M., R.J.A.F., J.G., R.M.N., C.H., P.C.K.) and the Institute for Regenerative Medicine (R.M.N., C.H.) and the Center for Molecular Cardiology (P.C.K.), University of Zurich - all in Schlieren, Switzerland
| | - Arnt V Kristen
- From Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, CIBERCV, and Centro Nacional de Investigaciones Cardiovasculares, Madrid, and Universidad Francisco de Vitoria, Pozuelo de Alarcón - all in Spain (P.G.-P.); the Department of Cardiology, University Hospital Heidelberg, Heidelberg (F.S.), and Cardiovascular Center Darmstadt, Darmstadt (A.V.K.) - both in Germany; the Department of Cardiology, University of Rennes, Centre Hospitalier Universitaire (CHU) de Rennes, INSERM, LTSI-UMR 1099, Rennes (E.D.), Service de Cardiologie, CHU de Toulouse-Hôpital Rangueil, Toulouse (O.L.), and the Cardiology Department and French National Reference Center for Cardiac Amyloidosis, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, and Institut Mondor de Recherche Biomédicale, INSERM, Université Paris Est Créteil, Créteil (T.D.) - all in France; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); Alexion-AstraZeneca Rare Disease, Boston (M.F.M.); and Neurimmune (A.M., R.J.A.F., J.G., R.M.N., C.H., P.C.K.) and the Institute for Regenerative Medicine (R.M.N., C.H.) and the Center for Molecular Cardiology (P.C.K.), University of Zurich - all in Schlieren, Switzerland
| | - Michele F Mercuri
- From Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, CIBERCV, and Centro Nacional de Investigaciones Cardiovasculares, Madrid, and Universidad Francisco de Vitoria, Pozuelo de Alarcón - all in Spain (P.G.-P.); the Department of Cardiology, University Hospital Heidelberg, Heidelberg (F.S.), and Cardiovascular Center Darmstadt, Darmstadt (A.V.K.) - both in Germany; the Department of Cardiology, University of Rennes, Centre Hospitalier Universitaire (CHU) de Rennes, INSERM, LTSI-UMR 1099, Rennes (E.D.), Service de Cardiologie, CHU de Toulouse-Hôpital Rangueil, Toulouse (O.L.), and the Cardiology Department and French National Reference Center for Cardiac Amyloidosis, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, and Institut Mondor de Recherche Biomédicale, INSERM, Université Paris Est Créteil, Créteil (T.D.) - all in France; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); Alexion-AstraZeneca Rare Disease, Boston (M.F.M.); and Neurimmune (A.M., R.J.A.F., J.G., R.M.N., C.H., P.C.K.) and the Institute for Regenerative Medicine (R.M.N., C.H.) and the Center for Molecular Cardiology (P.C.K.), University of Zurich - all in Schlieren, Switzerland
| | - Aubin Michalon
- From Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, CIBERCV, and Centro Nacional de Investigaciones Cardiovasculares, Madrid, and Universidad Francisco de Vitoria, Pozuelo de Alarcón - all in Spain (P.G.-P.); the Department of Cardiology, University Hospital Heidelberg, Heidelberg (F.S.), and Cardiovascular Center Darmstadt, Darmstadt (A.V.K.) - both in Germany; the Department of Cardiology, University of Rennes, Centre Hospitalier Universitaire (CHU) de Rennes, INSERM, LTSI-UMR 1099, Rennes (E.D.), Service de Cardiologie, CHU de Toulouse-Hôpital Rangueil, Toulouse (O.L.), and the Cardiology Department and French National Reference Center for Cardiac Amyloidosis, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, and Institut Mondor de Recherche Biomédicale, INSERM, Université Paris Est Créteil, Créteil (T.D.) - all in France; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); Alexion-AstraZeneca Rare Disease, Boston (M.F.M.); and Neurimmune (A.M., R.J.A.F., J.G., R.M.N., C.H., P.C.K.) and the Institute for Regenerative Medicine (R.M.N., C.H.) and the Center for Molecular Cardiology (P.C.K.), University of Zurich - all in Schlieren, Switzerland
| | - Robert J A Frost
- From Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, CIBERCV, and Centro Nacional de Investigaciones Cardiovasculares, Madrid, and Universidad Francisco de Vitoria, Pozuelo de Alarcón - all in Spain (P.G.-P.); the Department of Cardiology, University Hospital Heidelberg, Heidelberg (F.S.), and Cardiovascular Center Darmstadt, Darmstadt (A.V.K.) - both in Germany; the Department of Cardiology, University of Rennes, Centre Hospitalier Universitaire (CHU) de Rennes, INSERM, LTSI-UMR 1099, Rennes (E.D.), Service de Cardiologie, CHU de Toulouse-Hôpital Rangueil, Toulouse (O.L.), and the Cardiology Department and French National Reference Center for Cardiac Amyloidosis, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, and Institut Mondor de Recherche Biomédicale, INSERM, Université Paris Est Créteil, Créteil (T.D.) - all in France; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); Alexion-AstraZeneca Rare Disease, Boston (M.F.M.); and Neurimmune (A.M., R.J.A.F., J.G., R.M.N., C.H., P.C.K.) and the Institute for Regenerative Medicine (R.M.N., C.H.) and the Center for Molecular Cardiology (P.C.K.), University of Zurich - all in Schlieren, Switzerland
| | - Jan Grimm
- From Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, CIBERCV, and Centro Nacional de Investigaciones Cardiovasculares, Madrid, and Universidad Francisco de Vitoria, Pozuelo de Alarcón - all in Spain (P.G.-P.); the Department of Cardiology, University Hospital Heidelberg, Heidelberg (F.S.), and Cardiovascular Center Darmstadt, Darmstadt (A.V.K.) - both in Germany; the Department of Cardiology, University of Rennes, Centre Hospitalier Universitaire (CHU) de Rennes, INSERM, LTSI-UMR 1099, Rennes (E.D.), Service de Cardiologie, CHU de Toulouse-Hôpital Rangueil, Toulouse (O.L.), and the Cardiology Department and French National Reference Center for Cardiac Amyloidosis, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, and Institut Mondor de Recherche Biomédicale, INSERM, Université Paris Est Créteil, Créteil (T.D.) - all in France; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); Alexion-AstraZeneca Rare Disease, Boston (M.F.M.); and Neurimmune (A.M., R.J.A.F., J.G., R.M.N., C.H., P.C.K.) and the Institute for Regenerative Medicine (R.M.N., C.H.) and the Center for Molecular Cardiology (P.C.K.), University of Zurich - all in Schlieren, Switzerland
| | - Roger M Nitsch
- From Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, CIBERCV, and Centro Nacional de Investigaciones Cardiovasculares, Madrid, and Universidad Francisco de Vitoria, Pozuelo de Alarcón - all in Spain (P.G.-P.); the Department of Cardiology, University Hospital Heidelberg, Heidelberg (F.S.), and Cardiovascular Center Darmstadt, Darmstadt (A.V.K.) - both in Germany; the Department of Cardiology, University of Rennes, Centre Hospitalier Universitaire (CHU) de Rennes, INSERM, LTSI-UMR 1099, Rennes (E.D.), Service de Cardiologie, CHU de Toulouse-Hôpital Rangueil, Toulouse (O.L.), and the Cardiology Department and French National Reference Center for Cardiac Amyloidosis, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, and Institut Mondor de Recherche Biomédicale, INSERM, Université Paris Est Créteil, Créteil (T.D.) - all in France; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); Alexion-AstraZeneca Rare Disease, Boston (M.F.M.); and Neurimmune (A.M., R.J.A.F., J.G., R.M.N., C.H., P.C.K.) and the Institute for Regenerative Medicine (R.M.N., C.H.) and the Center for Molecular Cardiology (P.C.K.), University of Zurich - all in Schlieren, Switzerland
| | - Christoph Hock
- From Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, CIBERCV, and Centro Nacional de Investigaciones Cardiovasculares, Madrid, and Universidad Francisco de Vitoria, Pozuelo de Alarcón - all in Spain (P.G.-P.); the Department of Cardiology, University Hospital Heidelberg, Heidelberg (F.S.), and Cardiovascular Center Darmstadt, Darmstadt (A.V.K.) - both in Germany; the Department of Cardiology, University of Rennes, Centre Hospitalier Universitaire (CHU) de Rennes, INSERM, LTSI-UMR 1099, Rennes (E.D.), Service de Cardiologie, CHU de Toulouse-Hôpital Rangueil, Toulouse (O.L.), and the Cardiology Department and French National Reference Center for Cardiac Amyloidosis, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, and Institut Mondor de Recherche Biomédicale, INSERM, Université Paris Est Créteil, Créteil (T.D.) - all in France; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); Alexion-AstraZeneca Rare Disease, Boston (M.F.M.); and Neurimmune (A.M., R.J.A.F., J.G., R.M.N., C.H., P.C.K.) and the Institute for Regenerative Medicine (R.M.N., C.H.) and the Center for Molecular Cardiology (P.C.K.), University of Zurich - all in Schlieren, Switzerland
| | - Peter C Kahr
- From Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, CIBERCV, and Centro Nacional de Investigaciones Cardiovasculares, Madrid, and Universidad Francisco de Vitoria, Pozuelo de Alarcón - all in Spain (P.G.-P.); the Department of Cardiology, University Hospital Heidelberg, Heidelberg (F.S.), and Cardiovascular Center Darmstadt, Darmstadt (A.V.K.) - both in Germany; the Department of Cardiology, University of Rennes, Centre Hospitalier Universitaire (CHU) de Rennes, INSERM, LTSI-UMR 1099, Rennes (E.D.), Service de Cardiologie, CHU de Toulouse-Hôpital Rangueil, Toulouse (O.L.), and the Cardiology Department and French National Reference Center for Cardiac Amyloidosis, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, and Institut Mondor de Recherche Biomédicale, INSERM, Université Paris Est Créteil, Créteil (T.D.) - all in France; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); Alexion-AstraZeneca Rare Disease, Boston (M.F.M.); and Neurimmune (A.M., R.J.A.F., J.G., R.M.N., C.H., P.C.K.) and the Institute for Regenerative Medicine (R.M.N., C.H.) and the Center for Molecular Cardiology (P.C.K.), University of Zurich - all in Schlieren, Switzerland
| | - Thibaud Damy
- From Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, CIBERCV, and Centro Nacional de Investigaciones Cardiovasculares, Madrid, and Universidad Francisco de Vitoria, Pozuelo de Alarcón - all in Spain (P.G.-P.); the Department of Cardiology, University Hospital Heidelberg, Heidelberg (F.S.), and Cardiovascular Center Darmstadt, Darmstadt (A.V.K.) - both in Germany; the Department of Cardiology, University of Rennes, Centre Hospitalier Universitaire (CHU) de Rennes, INSERM, LTSI-UMR 1099, Rennes (E.D.), Service de Cardiologie, CHU de Toulouse-Hôpital Rangueil, Toulouse (O.L.), and the Cardiology Department and French National Reference Center for Cardiac Amyloidosis, Hôpitaux Universitaires Henri Mondor, Assistance Publique-Hôpitaux de Paris, and Institut Mondor de Recherche Biomédicale, INSERM, Université Paris Est Créteil, Créteil (T.D.) - all in France; the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (P.M.); Alexion-AstraZeneca Rare Disease, Boston (M.F.M.); and Neurimmune (A.M., R.J.A.F., J.G., R.M.N., C.H., P.C.K.) and the Institute for Regenerative Medicine (R.M.N., C.H.) and the Center for Molecular Cardiology (P.C.K.), University of Zurich - all in Schlieren, Switzerland
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Porcari A, Sinagra G, Quarta CC, Fontana M, Gillmore JD. Final farewell to Claudio Rapezzi: observation, deduction and knowledge in medicine. Front Cardiovasc Med 2023; 10:1221983. [PMID: 37378409 PMCID: PMC10291057 DOI: 10.3389/fcvm.2023.1221983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 05/30/2023] [Indexed: 06/29/2023] Open
Affiliation(s)
- Aldostefano Porcari
- National Amyloidosis Centre, Division of Medicine, University College London, London, United Kingdom
- Centre for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Trieste, Italy
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart
| | - Gianfranco Sinagra
- Centre for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Trieste, Italy
- European Reference Network for Rare, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart
| | - Cristina Candida Quarta
- National Amyloidosis Centre, Division of Medicine, University College London, London, United Kingdom
| | - Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, University College London, London, United Kingdom
| | - Julian D. Gillmore
- National Amyloidosis Centre, Division of Medicine, University College London, London, United Kingdom
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Cersosimo A, Bonelli A, Lombardi CM, Moreo A, Pagnesi M, Tomasoni D, Arabia G, Vizzardi E, Adamo M, Farina D, Metra M, Inciardi RM. Multimodality imaging in the diagnostic management of concomitant aortic stenosis and transthyretin-related wild-type cardiac amyloidosis. Front Cardiovasc Med 2023; 10:1108696. [PMID: 36998972 PMCID: PMC10043370 DOI: 10.3389/fcvm.2023.1108696] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Accepted: 02/21/2023] [Indexed: 03/17/2023] Open
Abstract
Severe aortic stenosis (AS) is the most common valvular heart disease with a prevalence rate of more than 4% in 75-year-old people or older. Similarly, cardiac amyloidosis (CA), especially "wild-type transthyretin" (wTTR), has shown a prevalence rate ranging from 22% to 25% in people older than 80 years. The detection of the concomitant presence of CA and AS is challenging primarily because of the similar type of changes in the left ventricle caused by AS and CA, which share some morphological characteristics. The aim of this review is to identify the imaging triggers in order to recognize occult wtATTR-CA in patients with AS, clarifying the crucial step of the diagnostic process. Multimodality imaging methods such as echocardiography, cardiac magnetic resonance, cardiac computed tomography, and DPD scintigraphy will be analyzed as part of the available diagnostic workup to identify wtATTR-CA early in patients with AS.
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Affiliation(s)
- Angelica Cersosimo
- ASST Spedali Civili di Brescia, Division of Cardiology and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Andrea Bonelli
- ASST Grande Ospedale Metropolitano Niguarda, "A. De Gasperis" Department, Cardiology IV, Milan, Italy
| | - Carlo M Lombardi
- ASST Spedali Civili di Brescia, Division of Cardiology and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Antonella Moreo
- ASST Grande Ospedale Metropolitano Niguarda, "A. De Gasperis" Department, Cardiology IV, Milan, Italy
| | - Matteo Pagnesi
- ASST Spedali Civili di Brescia, Division of Cardiology and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Daniela Tomasoni
- ASST Spedali Civili di Brescia, Division of Cardiology and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Gianmarco Arabia
- ASST Spedali Civili di Brescia, Division of Cardiology and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Enrico Vizzardi
- ASST Spedali Civili di Brescia, Division of Cardiology and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- ASST Spedali Civili di Brescia, Division of Cardiology and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Davide Farina
- ASST Spedali Civili di Brescia, Division of Radiology and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marco Metra
- ASST Spedali Civili di Brescia, Division of Cardiology and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Riccardo M Inciardi
- ASST Spedali Civili di Brescia, Division of Cardiology and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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Khedraki R, Robinson AA, Jordan T, Grodin JL, Mohan RC. A Review of Current and Evolving Imaging Techniques in Cardiac Amyloidosis. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2023; 25:43-63. [PMID: 38239280 PMCID: PMC10795761 DOI: 10.1007/s11936-023-00976-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/30/2022] [Indexed: 03/07/2023]
Abstract
Purpose of review Establishing an early, efficient diagnosis for cardiac amyloid (CA) is critical to avoiding adverse outcomes. We review current imaging tools that can aid early diagnosis, offer prognostic information, and possibly track treatment response in CA. Recent findings There are several current conventional imaging modalities that aid in the diagnosis of CA including electrocardiography, echocardiography, bone scintigraphy, cardiac computed tomography (CT), and cardiac magnetic resonance (CMR) imaging. Advanced imaging techniques including left atrial and right ventricular strain, and CMR T1 and T2 mapping as well as ECV quantification may provide alternative non-invasive means for diagnosis, more granular prognostication, and the ability to track treatment response. Summary Leveraging a multimodal imaging toolbox is integral to the early diagnosis of CA; however, it is important to understand the unique role and limitations posed by each modality. Ongoing studies are needed to help identify imaging markers that will lead to an enhanced ability to diagnose, subtype and manage this condition.
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Affiliation(s)
- Rola Khedraki
- Section of Advanced Heart Failure, Division of Cardiovascular Medicine, Scripps Clinic, Prebys Cardiovascular Institute, 9898 Genesee Ave., AMP-300, La Jolla, San Diego, CA 92037, USA
| | - Austin A. Robinson
- Section of Advanced Heart Failure, Division of Cardiovascular Medicine, Scripps Clinic, Prebys Cardiovascular Institute, 9898 Genesee Ave., AMP-300, La Jolla, San Diego, CA 92037, USA
| | - Timothy Jordan
- Section of Advanced Heart Failure, Division of Cardiovascular Medicine, Scripps Clinic, Prebys Cardiovascular Institute, 9898 Genesee Ave., AMP-300, La Jolla, San Diego, CA 92037, USA
| | - Justin L. Grodin
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, USA
| | - Rajeev C. Mohan
- Section of Advanced Heart Failure, Division of Cardiovascular Medicine, Scripps Clinic, Prebys Cardiovascular Institute, 9898 Genesee Ave., AMP-300, La Jolla, San Diego, CA 92037, USA
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20
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Khor YM, Cuddy SAM, Singh V, Falk RH, Di Carli MF, Dorbala S. 99mTc Bone-Avid Tracer Cardiac Scintigraphy: Role in Noninvasive Diagnosis of Transthyretin Cardiac Amyloidosis. Radiology 2023; 306:e221082. [PMID: 36537896 PMCID: PMC9885342 DOI: 10.1148/radiol.221082] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 08/11/2022] [Accepted: 09/15/2022] [Indexed: 12/24/2022]
Abstract
Transthyretin cardiac amyloidosis (ATTR-CA) is an overlooked cause of heart failure, with substantial morbidity and mortality. The emergence of several novel therapies has fueled the interest in early and accurate diagnosis of ATTR-CA so that potentially life-saving pharmacologic therapy can be administered in a timely manner. The most promising imaging modality and biomarker is SPECT imaging with technetium 99m (99mTc)-radiolabeled bone-seeking tracers, which have high specificity in the diagnosis of ATTR-CA, potentially obviating biopsy. In this article, the authors provide a focused review on the use of 99mTc pyrophosphate (PYP), 3,3-diphosphono-1,2-propanodicarboxylic acid (DPD), and hydroxymethylene diphosphonate (HMDP) for diagnosis of ATTR-CA, present a systematic approach to interpretation of the scans, and highlight several common pitfalls to illustrate important diagnostic principles for accurate interpretation of these images. The authors indicate when to use endomyocardial biopsy for the diagnosis of cardiac amyloidosis and conclude with a section on quantitation of 99mTc-PYP/DPD/HMDP imaging.
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Affiliation(s)
- Yiu Ming Khor
- From the Department of Nuclear Medicine and Molecular Imaging,
Singapore General Hospital, Singapore (Y.M.K.); Division of Nuclear Medicine and
Molecular Imaging, Department of Radiology (Y.M.K., V.S., M.F.D.C., S.D.),
Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine
(S.A.M.C., R.H.F., S.D.), and CV Imaging Program, Cardiovascular Division and
Department of Radiology (S.A.M.C., V.S., M.F.D.C., S.D.), Brigham and
Women’s Hospital and Harvard Medical School, 70 Francis St, Boston, MA
02115; and Midwest Heart and Vascular Specialists, HCA Midwest Health, Kansas
City, Mo (V.S.)
| | - Sarah A. M. Cuddy
- From the Department of Nuclear Medicine and Molecular Imaging,
Singapore General Hospital, Singapore (Y.M.K.); Division of Nuclear Medicine and
Molecular Imaging, Department of Radiology (Y.M.K., V.S., M.F.D.C., S.D.),
Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine
(S.A.M.C., R.H.F., S.D.), and CV Imaging Program, Cardiovascular Division and
Department of Radiology (S.A.M.C., V.S., M.F.D.C., S.D.), Brigham and
Women’s Hospital and Harvard Medical School, 70 Francis St, Boston, MA
02115; and Midwest Heart and Vascular Specialists, HCA Midwest Health, Kansas
City, Mo (V.S.)
| | - Vasvi Singh
- From the Department of Nuclear Medicine and Molecular Imaging,
Singapore General Hospital, Singapore (Y.M.K.); Division of Nuclear Medicine and
Molecular Imaging, Department of Radiology (Y.M.K., V.S., M.F.D.C., S.D.),
Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine
(S.A.M.C., R.H.F., S.D.), and CV Imaging Program, Cardiovascular Division and
Department of Radiology (S.A.M.C., V.S., M.F.D.C., S.D.), Brigham and
Women’s Hospital and Harvard Medical School, 70 Francis St, Boston, MA
02115; and Midwest Heart and Vascular Specialists, HCA Midwest Health, Kansas
City, Mo (V.S.)
| | - Rodney H. Falk
- From the Department of Nuclear Medicine and Molecular Imaging,
Singapore General Hospital, Singapore (Y.M.K.); Division of Nuclear Medicine and
Molecular Imaging, Department of Radiology (Y.M.K., V.S., M.F.D.C., S.D.),
Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine
(S.A.M.C., R.H.F., S.D.), and CV Imaging Program, Cardiovascular Division and
Department of Radiology (S.A.M.C., V.S., M.F.D.C., S.D.), Brigham and
Women’s Hospital and Harvard Medical School, 70 Francis St, Boston, MA
02115; and Midwest Heart and Vascular Specialists, HCA Midwest Health, Kansas
City, Mo (V.S.)
| | - Marcelo F. Di Carli
- From the Department of Nuclear Medicine and Molecular Imaging,
Singapore General Hospital, Singapore (Y.M.K.); Division of Nuclear Medicine and
Molecular Imaging, Department of Radiology (Y.M.K., V.S., M.F.D.C., S.D.),
Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine
(S.A.M.C., R.H.F., S.D.), and CV Imaging Program, Cardiovascular Division and
Department of Radiology (S.A.M.C., V.S., M.F.D.C., S.D.), Brigham and
Women’s Hospital and Harvard Medical School, 70 Francis St, Boston, MA
02115; and Midwest Heart and Vascular Specialists, HCA Midwest Health, Kansas
City, Mo (V.S.)
| | - Sharmila Dorbala
- From the Department of Nuclear Medicine and Molecular Imaging,
Singapore General Hospital, Singapore (Y.M.K.); Division of Nuclear Medicine and
Molecular Imaging, Department of Radiology (Y.M.K., V.S., M.F.D.C., S.D.),
Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine
(S.A.M.C., R.H.F., S.D.), and CV Imaging Program, Cardiovascular Division and
Department of Radiology (S.A.M.C., V.S., M.F.D.C., S.D.), Brigham and
Women’s Hospital and Harvard Medical School, 70 Francis St, Boston, MA
02115; and Midwest Heart and Vascular Specialists, HCA Midwest Health, Kansas
City, Mo (V.S.)
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Wan Ahmad WA, Mohd Ghazi A, Abdul Ghapar AK, Muthusamy TS, Liew HB, Zainal Abidin I, Ong ML, Ross NT, Cham YL, Ho WS, Fegade M, Chew DSP. From Primary to Tertiary Care: Expert Position Statements to Guide Heart Failure with Preserved Ejection Fraction Diagnosis. Malays J Med Sci 2023; 30:49-66. [PMID: 36875198 PMCID: PMC9984115 DOI: 10.21315/mjms2023.30.1.5] [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: 04/05/2022] [Accepted: 07/31/2022] [Indexed: 03/05/2023] Open
Abstract
Globally, heart failure with preserved ejection fraction (HFpEF) is quickly becoming the dominant form of heart failure (HF) in ageing populations. However, there are still multiple gaps and challenges in making a firm diagnosis of HFpEF in many low-to-middle income Asian countries. In response to this unmet need, the Malaysian HFpEF Working Group (MY-HPWG) gathered and reviewed evidence surrounding the use of different diagnostic modalities indicated for patients with HFpEF to identify diagnostic tools that could be conveniently accessed across different healthcare settings. As a result, five recommendation statements were proposed and an accompanying algorithm was developed, with the aim of improving the diagnostic rate of HFpEF. The MY-HPWG recommends using more easily accessible and non-invasive tools, such as natriuretic peptide (NP) biomarkers and basic echocardiogram (ECHO), to ensure timely HFpEF diagnosis in the primary and secondary care settings, and prompt referral to a tertiary care centre for more comprehensive assessments in uncertain cases.
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Affiliation(s)
- Wan Azman Wan Ahmad
- Division of Cardiology, Department of Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Azmee Mohd Ghazi
- Cardiology Department, The National Heart Institute of Malaysia, Kuala Lumpur, Malaysia
| | | | | | - Houng Bang Liew
- Cardiology Department, Queen Elizabeth Hospital II, Sabah, Malaysia
| | - Imran Zainal Abidin
- Department of Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Mei Lin Ong
- Cardiology Department, Gleneagles Hospital Penang, Pulau Pinang, Malaysia
| | - Noel Thomas Ross
- Medical Department, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia
| | - Yee Ling Cham
- Cardiology Department, Sarawak Heart Centre, Sarawak, Malaysia
| | - Wing Sze Ho
- Novartis Corporation (Malaysia) Sdn. Bhd., Selangor, Malaysia
| | - Mayuresh Fegade
- Novartis Corporation (Malaysia) Sdn. Bhd., Selangor, Malaysia
| | - David Soon Ping Chew
- Cardiology Department, Cardiac Vascular Sentral Kuala Lumpur, Kuala Lumpur, Malaysia
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22
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Wollenweber T, Kretschmer-Chott E, Wurm R, Rasul S, Kulterer O, Rettl R, Duca F, Bonderman D, Sühs KW, Hacker M, Traub-Weidinger T. Does [99mTc]-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) soft tissue uptake allow the identification of patients with the diagnosis of cardiac transthyretin-related (ATTR) amyloidosis with higher risk for polyneuropathy? J Nucl Cardiol 2023; 30:357-367. [PMID: 35817943 PMCID: PMC9984356 DOI: 10.1007/s12350-022-02986-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Accepted: 03/26/2022] [Indexed: 01/15/2023]
Abstract
BACKGROUND With the introduction of several drugs for the therapy of transthyretin-related amyloidosis (ATTR) which slow down the disease, early detection of polyneuropathy (PNP) is becoming increasingly of interest. [99mTc]-3,3-Diphosphono-1,2-Propanodicarboxylic Acid (DPD) bone scintigraphy, which is used for the diagnosis of cardiac (c)ATTR, can possibly make an important contribution in the identification of patients at risk for PNP. METHODS Fifty patients with cATTR, who underwent both planar whole-body DPD scintigraphy and nerve conduction studies (NCS) were retrospectively evaluated. A subgroup of 22 patients also underwent quantitative SPECT/CT of the thorax from which Standardized Uptake Values (SUVpeak) in the subcutaneous fat tissue of the left axillar region were evaluated. RESULTS The Perugini score was significantly increased in patients with cATTR and additional diagnosis of PNP compared to patients without (2.51 ± 0.51 vs 2.13 ± 0.52; P = 0.03). Quantitative SPECT/CT revealed that DPD uptake in the subcutaneous fat of the left axillar region was significantly increased in cATTR patients with compared to patients without (1.36 ± 0.60 vs 0.74 ± 0.52; P = 0.04). CONCLUSION This study suggests that DPD bone scintigraphy is a useful tool for identification of patients with cATTR and a risk for PNP due to increased DPD soft tissue uptake.
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Affiliation(s)
- Tim Wollenweber
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Elisabeth Kretschmer-Chott
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Raphael Wurm
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Sazan Rasul
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Oana Kulterer
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Rene Rettl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Franz Duca
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Diana Bonderman
- 5th Medical Department with Cardiology, Clinic Favoriten, Vienna, Austria
| | | | - Marcus Hacker
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Tatjana Traub-Weidinger
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
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23
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Avalon JC, Fuqua J, Deskins S, Miller T, Conte J, Martin D, Marano G, Yanamala N, Mills J, Bianco C, Patel B, Seetharam K, Raylman R, Sengupta PP, Hamirani YS. Quantitative single photon emission computed tomography derived standardized uptake values on 99mTc-PYP scan in patients with suspected ATTR cardiac amyloidosis. J Nucl Cardiol 2023; 30:127-139. [PMID: 35655113 DOI: 10.1007/s12350-022-02988-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2021] [Accepted: 04/02/2022] [Indexed: 01/15/2023]
Abstract
Technetium-99 pyrophosphate scintigraphy (99mTc-PYP) provides qualitative and semiquantitative diagnosis of ATTR cardiac amyloidosis (ATTR-CA) using the Perugini scoring system and heart/contralateral heart ratio (H/CL) on planar imaging. Standardized uptake values (SUV) with quantitative single photon emission computed tomography (xSPECT/CT) can offer superior diagnostic accuracy and quantification through precise myocardial contouring that enhances assessment of ATTR-CA burden. We examined the correlation of xSPECT/CT SUVs with Perugini score and H/CL ratio. We also assessed SUV correlation with cardiac magnetic resonance (CMR), echocardiographic, and baseline clinical characteristics. Retrospective review of 78 patients with suspected ATTR-CA that underwent 99mTc-PYP scintigraphy with xSPECT/CT. Patients were grouped off Perugini score (Grade 0-1 and Grade 2-3), H/CL ratio (≥ 1.5 and < 1.5). Two cohorts were also created: myocardium SUVmax > 1.88 and ≤ 1.88 at 1-hour based off an AUC curve with 1.88 showing the greatest sensitivity and specificity. Cardiac SUV retention index was calculated as [SUVmax myocardium/SUVmax vertebrae] × SUVmax paraspinal muscle. Primary outcome was myocardium SUVmax at 1-hour correlation with Perugini grades, H/CL ratio, CMR, and echocardiographic data. Higher Perugini Grades corresponded with higher myocardium SUVmax values, especially when comparing Perugini Grade 3 to Grade 2 and 1 (3.03 ± 2.1 vs 0.59 ± 0.97 and 0.09 ± 0.2, P < 0.001). Additionally, patients with H/CL ≥ 1.5 had significantly higher myocardium SUVmax compared to patients with H/CL ≤ 1.5 (2.92 ± 2.18 vs 0.35 ± 0.60, P < 0.01). Myocardium SUVmax at 1-hour strongly correlated with ECV (r = 0.91, P = 0.001), pre-contrast T1 map values (r = 0.66, P = 0.037), and left ventricle mass index (r = 0.80, P = 0.002) on CMR. SUVs derived from 99mTc-PYP scintigraphy with xSPECT/CT provides a discriminatory and quantitative method to diagnose and assess ATTR-CA burden. These findings strongly correlate with CMR.
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Affiliation(s)
| | - Jacob Fuqua
- School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Seth Deskins
- School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Tyler Miller
- School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Justin Conte
- School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Daniel Martin
- Department of Radiology, West Virginia University, Morgantown, WV, USA
| | - Gary Marano
- Department of Radiology, West Virginia University, Morgantown, WV, USA
| | - Naveena Yanamala
- Heart and Vascular Institute, West Virginia University, 1 Medical Center Dr, Morgantown, WV, 26506, USA
| | - James Mills
- Heart and Vascular Institute, West Virginia University, 1 Medical Center Dr, Morgantown, WV, 26506, USA
| | - Christopher Bianco
- Heart and Vascular Institute, West Virginia University, 1 Medical Center Dr, Morgantown, WV, 26506, USA
| | - Brijesh Patel
- Heart and Vascular Institute, West Virginia University, 1 Medical Center Dr, Morgantown, WV, 26506, USA
| | - Karthik Seetharam
- Heart and Vascular Institute, West Virginia University, 1 Medical Center Dr, Morgantown, WV, 26506, USA
| | - Raymond Raylman
- Department of Radiology, West Virginia University, Morgantown, WV, USA
| | - Partho P Sengupta
- Division of Cardiovascular Disease and Hypertension, Rutgers Robert Wood Johnson Medical School, 125 Patterson St, New Brunswick, NJ, 08901, USA
| | - Yasmin S Hamirani
- Heart and Vascular Institute, West Virginia University, 1 Medical Center Dr, Morgantown, WV, 26506, USA.
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24
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Salvalaggio A, Cipriani A, Righetto S, Artioli P, Sinigiani G, De Michieli L, Cason M, Pilichou K, Cecchin D, Briani C. Incidental cardiac uptake of 99mTc-diphosphonates is predictive of poor outcome: data from 9616 bone scintigraphies. J Nucl Cardiol 2022; 29:3419-3425. [PMID: 35437680 DOI: 10.1007/s12350-022-02961-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 02/27/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Bone scintigraphy (BS) is highly diagnostic for amyloid transthyretin (ATTR) cardiomyopathy. Prevalence and prognostic value of BS cardiac uptake is not well established. Our aim was to assess the prevalence of subclinical cardiac ATTR amyloidosis in patients undergoing [99mTc]MDP/DPD scintigraphy and to define their phenotype and prognosis. METHODS AND RESULTS BS scans performed for any clinical indications from 2009 to 2020 were reviewed. Patients were stratified according to Perugini visual score of cardiac uptake. Follow-up data were collected. Among 9616 BS scans, 0.7% (n = 67) showed cardiac uptake. In 47 (70%) patients, Perugini score was 1 and in 20 (30%) patients uptake was ≥ 2, suggesting cardiac ATTR amyloidosis. Forty subjects (61%) died during the follow-up (mean 47 ± 30 months). Compared with patients with Perugini score 1, those Perugini score ≥ 2 showed increased death rate (P = .018). Two (2/67) subjects were investigated for TTR gene mutations resulting negative. CONCLUSIONS In patients undergoing BS for different clinical indications, cardiac uptake suggesting cardiac ATTR amyloidosis is a rare, but still neglected finding, thus preventing possible diagnosis of ATTR cardiomyopathy. Importantly, cardiac uptake negatively affects the survival. Physicians should be aware of this rare, but crucial finding for timely diagnosis and treatment.
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Affiliation(s)
- A Salvalaggio
- Department of Neurosciences, University of Padova, Via Giustiniani 5, 35128, Padua, Italy
- Padova Neuroscience Center (PNC), University of Padova, Padua, Italy
| | - A Cipriani
- Department of Cardio- Thoraco-Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - S Righetto
- Department of Neurosciences, University of Padova, Via Giustiniani 5, 35128, Padua, Italy
| | - P Artioli
- Department of Medicine (DIMED), Nuclear Medicine Unit, University-Hospital of Padova, Padua, Italy
| | - G Sinigiani
- Department of Cardio- Thoraco-Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - L De Michieli
- Department of Cardio- Thoraco-Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - M Cason
- Department of Cardio- Thoraco-Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - K Pilichou
- Department of Cardio- Thoraco-Vascular Sciences and Public Health, University of Padova, Padua, Italy
| | - D Cecchin
- Department of Medicine (DIMED), Nuclear Medicine Unit, University-Hospital of Padova, Padua, Italy
| | - C Briani
- Department of Neurosciences, University of Padova, Via Giustiniani 5, 35128, Padua, Italy.
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25
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AL-Type Amyloidosis Involving Stomach and Lungs in 99m Tc-DPD Bone Scan. Clin Nucl Med 2022; 47:1059-1060. [PMID: 35835133 DOI: 10.1097/rlu.0000000000004336] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
ABSTRACT Systemic AL (amyloid light-chain) amyloidosis is a relatively rare disease. 99m Tc-DPD (3,3-diphosphono-1,2-pyrophosphate) bone scan is a highly sensitive diagnostic tool for cardiac amyloidosis of ATTR (transthyretin) type. In AL amyloidosis, there have been some previous reports of extracardiac DPD uptake in liver, kidney, and spleen, but not in stomach. We present 99m Tc-DPD bone scan images of AL-type amyloidosis involving stomach and lung.
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26
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Isotani Y, Amiya E, Ishida J, Komuro I. Summation of Precordial R Wave Amplitudes, a Clinical Parameter for Detecting Early TTR Amyloidosis Cardiac Involvement. J Cardiovasc Dev Dis 2022; 9:jcdd9100348. [PMID: 36286300 PMCID: PMC9604937 DOI: 10.3390/jcdd9100348] [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: 08/29/2022] [Revised: 10/05/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022] Open
Abstract
There have been several reports on the identification of the stage of transthyretin amyloid cardiomyopathy (ATTR-CM); however, a staging system for ATTR-CM has not yet been established. An 83-year-old woman was referred to our department about ten years ago. Recently, she was diagnosed with ATTR-CM. The electrocardiogram showed characteristic changes that take place over the duration of ATTR-CM progression. Among these, the precordial R amplitudes abruptly decreased before the development of increased ventricular thickness. This case suggested that the decrease in the precordial R wave amplitudes may represent a new diagnostic clue reflecting early myocardial damage due to ATTR-CM.
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Affiliation(s)
- Yoshitaka Isotani
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Eisuke Amiya
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
- Department of Therapeutic Strategy for Heart Failure, University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
- Correspondence: ; Tel.: +81-3-3815-5411 or +81-3-5800-9595
| | - Junichi Ishida
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
| | - Issei Komuro
- Department of Cardiovascular Medicine, Graduate School of Medicine, University of Tokyo, Hongo 7-3-1, Bunkyo-ku, Tokyo 113-8655, Japan
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27
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de Marneffe N, Dulgheru R, Ancion A, Moonen M, Lancellotti P. Cardiac amyloidosis: a review of the literature. Acta Cardiol 2022; 77:683-692. [PMID: 35852493 DOI: 10.1080/00015385.2021.1992990] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Cardiac amyloidosis is a rare disease associated with severe morbidity and mortality. There are three main types of amyloidosis associated with cardiac involvement: light chain (AL), familial or senile (ATTR) and secondary amyloidosis (AA). Cardiac amyloidosis often results in heart failure with preserved left ventricular ejection fraction, may display echocardiographic features of restrictive cardiomyopathy associated with left ventricular hypertrophy or mimic hypertrophic obstructive cardiomyopathy. However, left ventricular systolic dysfunction and normal wall thickness can sometimes be encountered. Imaging studies (echocardiography, bone scintigraphy, cardiac magnetic resonance) and blood and urine analysis are usually the main tools for the diagnosis. Sometimes, a tissue biopsy may be necessary. Treatment, which is constantly improving, will be carried out on two fronts: treatment of the symptoms and complications that the disease already caused and prevention of additional amyloid deposits while managing the concomitant complications. The purpose of this article is to review the management of cardiac amyloidosis.
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Affiliation(s)
- Nils de Marneffe
- Department of Cardiology, University Hospital of Liege, Liege, Belgium
| | - R Dulgheru
- Head of Clinic, Department of Cardiology, University Hospital of Liege, Liege, Belgium
| | - A Ancion
- Head of Clinic, Department of Cardiology, University Hospital of Liege, Liege, Belgium
| | - M Moonen
- Head of Clinic, Department of Cardiology, University Hospital of Liege, Liege, Belgium
| | - P Lancellotti
- Professor at the University of Liege, Head of the Cardiology Department, Director of the Cardiovascular GIGA, University Hospital of Liege
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28
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Nuclear Molecular Imaging of Disease Burden and Response to Treatment for Cardiac Amyloidosis. BIOLOGY 2022; 11:biology11101395. [PMID: 36290299 PMCID: PMC9598720 DOI: 10.3390/biology11101395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/20/2022] [Accepted: 09/21/2022] [Indexed: 11/16/2022]
Abstract
Simple Summary Cardiac amyloidosis (CA) is characterized by extracellular infiltration and deposition of amyloid fibrils primarily derived from the circulating transthyretin protein (TTR) or immunoglobulin light chain (AL). With the development of non-invasive diagnostic approaches and the emergence of new pharmacotherapeutic treatments for CA, the transformative effects of bone scintigraphy have been important in diagnosing TTR-CA. Positron emission tomography (PET) imaging is another promising, non-invasive option for the diagnosis of CA and may help differentiate between ATTR and AL amyloidosis. Bone-seeking single-photon emission tomography/computed tomography (SPECT/CT) quantification and amyloid-targeting PET imaging could be useful as a new strategy for disease burden and therapy monitoring to provide more insights into therapy response assessed by quantifying the amyloid burden in CA. Abstract Cardiac amyloidosis (CA) is a heterogeneous group of diseases in which extracellular insoluble amyloid proteins are deposited in specific organs and tissues locally or systemically, thereby interfering with physiological function. Transthyretin protein (TTR) and light chain (AL) amyloidosis are the most common types of cardiac amyloidosis. Radionuclide bone scintigraphy has recently become the most common non-invasive test for the diagnosis of TTR-CA but is of limited value for the diagnosis of AL-CA. PET has proved promising for the diagnosis of CA and its applications are expected to expand in the future. This review summarizes the current bone scintigraphy and amyloid-targeting Positron emission tomography (PET) imaging, the binding imaging properties of radiotracers, and the values of diagnosis, prognosis, and monitoring therapy response in CA.
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Velaga J, Liew C, Choo Poh AC, Lee PT, Lath N, Low SC, Bharadwaj P. Multimodality Imaging in the Diagnosis and Assessment of Cardiac Amyloidosis. World J Nucl Med 2022; 21:173-183. [PMID: 36060088 PMCID: PMC9436521 DOI: 10.1055/s-0042-1751057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
Amyloidosis is a rare disorder where abnormal protein aggregates are deposited in tissues forming amyloid fibrils, leading to progressive organ failure. Although any organ can be affected, cardiac involvement is the main cause of morbidity and mortality associated with amyloidosis as diagnosis is often delayed due to the indolent nature of the disease in some forms. An early diagnosis of disease and knowledge of the type/subtype of cardiac amyloidosis (CA) are essential for appropriate management and better outcome. Echocardiography is often the first line of investigation for patients suspected of CA and offers superior hemodynamic assessment. Although cardiovascular magnetic resonance (CMR) imaging is not diagnostic of CA, it provides vital clues to diagnosis and has a role in disease quantification and prognostication. Radiolabeled bone seeking tracers are the mainstay of diagnosis of CA and when combined with screening of monoclonal light chains, bone scintigraphy offers high sensitivity in diagnosing transthyretin type of CA. This review aims to describe the noninvasive imaging assessment and approach to diagnosis of patients with suspected CA. Imaging features of echocardiography, nuclear scintigraphy, and CMR are described with a brief mention on computed tomography.
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Affiliation(s)
- Jyothirmayi Velaga
- Department of Diagnostic Radiology, Singapore General Hospital, Singapore, Singapore
| | - Charlene Liew
- Department of Radiology, Changi General Hospital, Singapore, Singapore
| | | | | | - Narayan Lath
- Department of Diagnostic Radiology, Singapore General Hospital, Singapore, Singapore
| | - Shoen Choon Low
- Department of Diagnostic Radiology, Singapore General Hospital, Singapore, Singapore
| | - Pushan Bharadwaj
- Department of Nuclear Medicine and Molecular Imaging, Singapore General Hospital, Singapore
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Ioannou A, Patel RK, Razvi Y, Porcari A, Knight D, Martinez-Naharro A, Kotecha T, Venneri L, Chacko L, Brown J, Manisty C, Moon J, Wisniowski B, Lachmann H, Wechelakar A, Whelan C, Kellman P, Hawkins PN, Gillmore JD, Fontana M. Multi-Imaging Characterization of Cardiac Phenotype in Different Types of Amyloidosis. JACC Cardiovasc Imaging 2022; 16:464-477. [PMID: 36648052 DOI: 10.1016/j.jcmg.2022.07.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 07/01/2022] [Accepted: 07/07/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND Bone scintigraphy is extremely valuable when assessing patients with suspected cardiac amyloidosis (CA), but the clinical significance and associated phenotype of different degrees of cardiac uptake across different types is yet to be defined. OBJECTIVES This study sought to define the phenotypes of patients with varying degrees of cardiac uptake on bone scintigraphy, across multiple types of systemic amyloidosis, using extensive characterization comprising biomarkers as well as echocardiographic and cardiac magnetic resonance (CMR) imaging. METHODS A total of 296 patients (117 with immunoglobulin light-chain amyloidosis [AL], 165 with transthyretin (TTR) amyloidosis [ATTR], 7 with apolipoprotein AI amyloidosis [AApoAI], and 7 with apolipoprotein AIV amyloidosis [AApoAIV]) underwent deep characterization of their cardiac phenotype. RESULTS AL patients with grade 0 myocardial radiotracer uptake spanned the spectrum of CMR findings from no CA to characteristic CA, whereas AL patients with grades 1 to 3 always produced characteristic CMR features. In ATTR, the CA burden strongly correlated with myocardial tracer uptake, except in Ser77Tyr. AApoAI presented with grade 0 or 1 and disproportionate right-sided involvement. AApoAIV always presented with grade 0 and characteristic CA. AL grade 1 patients (n = 48; 100%) had characteristic CA, whereas only ATTR grade 1 patients with Ser77Tyr had characteristic CA on CMR (n = 5; 11.4%). After exclusion of Ser77Tyr, AApoAI, and AApoAIV, CMR showing characteristic CA or an extracellular volume of >0.40 in patients with grade 0 to 1 cardiac uptake had a sensitivity and specificity of 100% for AL. CONCLUSIONS There is a wide variation in cardiac phenotype between different amyloidosis types across different degrees of cardiac uptake. The combination of CMR and bone scintigraphy can help to define the diagnostic differentials and the clinical phenotype in each individual patient.
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Affiliation(s)
- Adam Ioannou
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Rishi K Patel
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Yousuf Razvi
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Aldostefano Porcari
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Daniel Knight
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Ana Martinez-Naharro
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Tushar Kotecha
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Lucia Venneri
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Liza Chacko
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - James Brown
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | | | - James Moon
- St Bartholomew's Hospital, London, United Kingdom
| | - Brendan Wisniowski
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Helen Lachmann
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Ashutosh Wechelakar
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Carol Whelan
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Peter Kellman
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland, USA
| | - Philip N Hawkins
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Julian D Gillmore
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom
| | - Marianna Fontana
- National Amyloidosis Centre, University College London, Royal Free Campus, London, United Kingdom.
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Antonopoulos AS, Panagiotopoulos I, Kouroutzoglou A, Koutsis G, Toskas P, Lazaros G, Toutouzas K, Tousoulis D, Tsioufis K, Vlachopoulos C. Prevalence and Clinical Outcomes of Transthyretin Amyloidosis: A Systematic Review and Meta-analysis. Eur J Heart Fail 2022; 24:1677-1696. [PMID: 35730461 DOI: 10.1002/ejhf.2589] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 06/10/2022] [Accepted: 06/18/2022] [Indexed: 11/07/2022] Open
Abstract
BACKGROUND Systematic evidence on the prevalence and clinical outcome of transthyretin amyloidosis (ATTR) is missing. We explored: a) the prevalence of cardiac amyloidosis in various patient subgroups, b) survival estimates for ATTR subtypes and c) the effects of novel therapeutics on the natural course of disease. METHODS A systematic review of literature published in Medline before 31/12/2021 was performed for the prevalence of cardiac amyloidosis & all-cause mortality of ATTR patients. Extracted data included sample size, age, sex, and all-cause mortality at 1, 2 and 5-years. Subgroup analyses were performed for ATTR subtype i.e., wild type ATTR (wtATTR) vs. hereditary ATTR (htATTR), htATTR genotypes and treatment subgroups. RESULTS We identified a total of 62 studies (n=277,882 individuals) reporting the prevalence of cardiac amyloidosis, which was high among patients with a hypertrophic cardiomyopathy phenotype, HFpEF, and elderly with aortic stenosis. Data on ATTR mortality were extracted from 95 studies (n=18,238 ATTR patients). Patients with wtATTR were older (p=7x10-10 ) and more frequently male (p=5x10-20 ) vs. htATTR. The 2-year survival of ATTR was 73.3% (95%CI 71.6-76.2); for non-subtyped ATTR 70.4% (95%CI 66.9-73.9), for wtATTR (76.0%, 95%CI: 73.0-78.9) and for htATTR (77.2%, 95%CI: 74.0-80.4); in meta-regression analysis wtATTR was associated with higher survival after adjusting for confounders. There was an interaction between survival and htATTR genotypes (p=10-15 , Val30Met having the lowest and Val122Ile/Thr60Ala the highest mortality). ATTR 2-year survival was higher on tafamidis/patisiran compared to natural disease course (79.9%, 95%CI: 74.4-85.3 vs. 72.4%, 95%CI 69.8-74.9, p<0.05). CONCLUSIONS We report the prevalence of ATTR in various population subgroups and provide survival estimates for the natural course of disease and the effects of novel therapeutics. Important gaps in worldwide epidemiology research in ATTR were identified. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Alexios S Antonopoulos
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Ioannis Panagiotopoulos
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Alexandrina Kouroutzoglou
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Georgios Koutsis
- Neurogenetics Unit, 1st Department of Neurology, National and Kapodistrian University of Athens, Eginition University Hospital, Athens, Greece
| | - Pantelis Toskas
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Georgios Lazaros
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Konstantinos Toutouzas
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Dimitris Tousoulis
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Konstantinos Tsioufis
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
| | - Charalambos Vlachopoulos
- 1st Cardiology Department, National and Kapodistrian University of Athens, Hippokration University Hospital, Athens, Greece
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Zhang LX, Martineau P, Finnerty V, Giraldeau G, Parent MC, Harel F, Pelletier-Galarneau M. Comparison of 18F-sodium fluoride positron emission tomography imaging and 99mTc-pyrophosphate in cardiac amyloidosis. J Nucl Cardiol 2022; 29:1132-1140. [PMID: 33146862 DOI: 10.1007/s12350-020-02425-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 10/17/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Pyrophosphate (PYP) scintigraphy provides high diagnostic accuracy for the detection of transthyretin (ATTR) cardiac amyloidosis (CA). There has recently been emerging interest in using 18F-sodium fluoride (NaF) for this application, yet its sensitivity has never been directly compared to that of PYP, the current molecular gold standard METHODS: Twelve subjects with ATTR-CA and 5 controls referred for PYP-SPECT were prospectively enrolled. 18F-NaF PET/CT scans were performed at 1 and 3 hours. Qualitative and quantitative analyses of the images were performed, and the sensitivity of 18F-NaF PET/CT and PYP-SPECT were compared RESULTS: Visual interpretation of NaF PET/CT yielded a sensitivity of 0.25 (95% CI 0.089 to 0.53) for the detection of ATTR-CA, which is significantly inferior to that of PYP-SPECT/CT (100%, P = .016). Visual interpretation at 3 hours yielded a similar sensitivity of 0.30 (95% CI 0.11 to 0.60, P = 1.00). There were no false-positive NaF PET studies. Mean target-to-background ratio (TBRmean) at 1h did not differ significantly (P = .21) in ATTR-CA subjects (0.83 ± 0.15) compared to controls (0.72 ± 0.15). Receiver operating characteristic (ROC) analysis yielded an area under the curve (AUC) of 0.69 ± 0.16 (95% CI 0.37 to 1.00, P = .23). CONCLUSION With qualitative and quantitative analyses, sensitivity of NaF PET/CT is significantly inferior to that of PYP-SPECT for the diagnosis of ATTR-CA.
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Affiliation(s)
- Li Xin Zhang
- Department of Medical Imaging, Institut de Cardiologie de Montréal, Montréal, Canada
| | | | - Vincent Finnerty
- Department of Medical Imaging, Institut de Cardiologie de Montréal, Montréal, Canada
| | - Geneviève Giraldeau
- Department of Medicine, Institut de Cardiologie de Montréal, Montréal, Canada
| | - Marie-Claude Parent
- Department of Medicine, Institut de Cardiologie de Montréal, Montréal, Canada
| | - François Harel
- Department of Medical Imaging, Institut de Cardiologie de Montréal, Montréal, Canada
| | - Matthieu Pelletier-Galarneau
- Department of Medical Imaging, Institut de Cardiologie de Montréal, Montréal, Canada.
- Gordon Center for Medical Imaging, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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Quaggin-Smith JA, Wehbe RM, Holly TA. Incidental detection of ATTR cardiac amyloidosis. J Nucl Cardiol 2022; 29:1030-1033. [PMID: 33426585 DOI: 10.1007/s12350-020-02467-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Accepted: 11/20/2020] [Indexed: 10/22/2022]
Affiliation(s)
| | - Ramsey M Wehbe
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, USA
| | - Thomas A Holly
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, USA.
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Ansheles AA, Nasonova SN, Zhirov IV, Saidova MA, Stukalova OV, Tereshchenko SN, Sergienko VB. Myocardial scintigraphy with <sup>99m</sup>Tc-pyrophosphate in the diagnosis of cardiac amyloidosis: place in the diagnostic algorithm, features of the implementation and interpretation of the study. TERAPEVT ARKH 2022; 94:530-537. [DOI: 10.26442/00403660.2022.04.201461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 05/25/2022] [Indexed: 11/22/2022]
Abstract
The article summarizes the current experience of the nuclear medicine department of the Chazov National Medical Research Center of Cardiology in the implementation of myocardium scintigraphy with 99mTc-pyrophosphate with the differential diagnosis of the types of cardiac amyloidosis. Causes of false-positive, equivocal and non-diagnostic results, are analyzed. Possible ways to eliminate mistakes, including by modifying protocols of planar and tomographic research and optimizing the whole diagnostic algorithm for amyloidosis of the heart, are discussed.
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Uusitalo V, Suomalainen O, Loimaala A, Mätzke S, Heliö T. Prognostic Value of 99mTc-HMDP Scintigraphy in Elderly Patients With Chronic Heart Failure. Heart Lung Circ 2022; 31:629-637. [PMID: 35063379 DOI: 10.1016/j.hlc.2021.11.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 11/20/2021] [Accepted: 11/28/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND This study evaluated the prevalence and prognostic significance of cardiac transthyretin amyloidosis (ATTR) diagnosed using 99mTc- hydroxymethylene-diphosphonate (99mTc-HMDP) scintigraphy in an elderly heart failure population. METHODS This retrospective study included 335 patients aged >70 years with heart failure and who underwent 99mTc-HMDP scintigraphy due to non-cardiac reasons in three imaging centres in Finland (Kymenlaakso Central Hospital, Jorvi Central Hospital, and Meilahti University Hospital). A Perugini grade >2 and heart-to-contralateral ratio (H/CL) of ≥1.30 were considered positive for cardiac ATTR. The overall and cardiovascular mortality were obtained from the national statistical service (Statistics Finland). RESULTS There were 234 deaths, of which 70 were classified as being due to cardiovascular causes during a median follow-up of 1 (1-3) year. Transthyretin amyloidosis was diagnosed in 22 patients (6.6%) using visual analysis and 17 patients using the H/CL ratio (5.1%). Patients with ATTR were older (85±5 vs 80±5 yrs; p=0.002) and had higher N-terminal pro-brain natriuretic peptide (NT-ProBNP) levels (1,451 [813-3,799] vs 6,192 [2,030-8,833] ng/L; p=0.02). Age, bone metastases, and glomerular filtration rate were independent predictors of overall mortality in multivariable analysis. Age, glomerular filtration rate, ≥grade 2 visual cardiac uptake, and H/CL ratio were independent predictors of cardiovascular mortality. CONCLUSIONS Cardiac uptake suggestive of ATTR was found in 5% of elderly patients with chronic heart failure. The presence of cardiac uptake on bone scintigraphy did not convey independent prognostic value on overall mortality but was independently associated with cardiovascular mortality.
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Affiliation(s)
- Valtteri Uusitalo
- Clinical Physiology and Nuclear Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland.
| | - Olli Suomalainen
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Antti Loimaala
- Clinical Physiology and Nuclear Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Sorjo Mätzke
- Clinical Physiology and Nuclear Medicine, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Tiina Heliö
- Heart and Lung Center, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Severi D, Aruta F, Iovino A, Spina E, Nolano M, Manganelli F, Tozza S. Can we identify hereditary TTR amyloidosis by the screening of carpal tunnel syndrome patients? Neurol Sci 2022; 43:3435-3438. [DOI: 10.1007/s10072-021-05851-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 12/20/2021] [Indexed: 10/19/2022]
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Andrews JPM, Trivieri MG, Everett R, Spath N, MacNaught G, Moss AJ, Doris MK, Pawade T, van Beek EJR, Lucatelli C, Newby DE, Robson P, Fayad ZA, Dweck MR. 18F-fluoride PET/MR in cardiac amyloid: A comparison study with aortic stenosis and age- and sex-matched controls. J Nucl Cardiol 2022; 29:741-749. [PMID: 33000405 PMCID: PMC8993737 DOI: 10.1007/s12350-020-02356-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Accepted: 08/19/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Cardiac MR is widely used to diagnose cardiac amyloid, but cannot differentiate AL and ATTR subtypes: an important distinction given their differing treatments and prognoses. We used PET/MR imaging to quantify myocardial uptake of 18F-fluoride in ATTR and AL amyloid patients, as well as participants with aortic stenosis and age/sex-matched controls. METHODS In this prospective multicenter study, patients were recruited in Edinburgh and New York and underwent 18F-fluoride PET/MR imaging. Standardized volumes of interest were drawn in the septum and areas of late gadolinium enhancement to derive myocardial standardized uptake values (SUV) and tissue-to-background ratio (TBRMEAN) after correction for blood pool activity in the right atrium. RESULTS 53 patients were scanned: 18 with cardiac amyloid (10 ATTR and 8 AL), 13 controls, and 22 with aortic stenosis. No differences in myocardial TBR values were observed between participants scanned in Edinburgh and New York. Mean myocardial TBRMEAN values in ATTR amyloid (1.13 ± 0.16) were higher than controls (0.84 ± 0.11, P = .0006), aortic stenosis (0.73 ± 0.12, P < .0001), and those with AL amyloid (0.96 ± 0.08, P = .01). TBRMEAN values within areas of late gadolinium enhancement provided discrimination between patients with ATTR (1.36 ± 0.23) and all other groups (e.g., AL [1.06 ± 0.07, P = .003]). A TBRMEAN threshold >1.14 in areas of LGE demonstrated 100% sensitivity (CI 72.25 to 100%) and 100% specificity (CI 67.56 to 100%) for ATTR compared to AL amyloid (AUC 1, P = .0004). CONCLUSION Quantitative 18F-fluoride PET/MR imaging can distinguish ATTR amyloid from other similar phenotypes and holds promise in improving the diagnosis of this condition.
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Affiliation(s)
- Jack P M Andrews
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Room SU.305, Chancellor's building, 51 Little France Crescent, Edinburgh, EH16 4SB, UK.
| | - Maria Giovanni Trivieri
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- BioMedical Engineering and Imaging Institute, New York, NY, USA
| | - Russell Everett
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Room SU.305, Chancellor's building, 51 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Nicholas Spath
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Room SU.305, Chancellor's building, 51 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Gillian MacNaught
- Edinburgh Imaging, Queen's Medical Research Institute University of Edinburgh, Edinburgh, UK
| | - Alastair J Moss
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Room SU.305, Chancellor's building, 51 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Mhairi K Doris
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Room SU.305, Chancellor's building, 51 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Tania Pawade
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Room SU.305, Chancellor's building, 51 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Edwin J R van Beek
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Room SU.305, Chancellor's building, 51 Little France Crescent, Edinburgh, EH16 4SB, UK
- Edinburgh Imaging, Queen's Medical Research Institute University of Edinburgh, Edinburgh, UK
| | - Christophe Lucatelli
- Edinburgh Imaging, Queen's Medical Research Institute University of Edinburgh, Edinburgh, UK
| | - David E Newby
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Room SU.305, Chancellor's building, 51 Little France Crescent, Edinburgh, EH16 4SB, UK
| | - Philip Robson
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- BioMedical Engineering and Imaging Institute, New York, NY, USA
| | - Zahi A Fayad
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
- BioMedical Engineering and Imaging Institute, New York, NY, USA
| | - Marc R Dweck
- British Heart Foundation Centre for Cardiovascular Science, University of Edinburgh, Room SU.305, Chancellor's building, 51 Little France Crescent, Edinburgh, EH16 4SB, UK
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Scheel PJ, Mukherjee M, Hays AG, Vaishnav J. Multimodality Imaging in the Evaluation and Prognostication of Cardiac Amyloidosis. Front Cardiovasc Med 2022; 9:787618. [PMID: 35402557 PMCID: PMC8989413 DOI: 10.3389/fcvm.2022.787618] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 02/14/2022] [Indexed: 11/13/2022] Open
Abstract
Cardiac amyloidosis (CA) is an infiltrative cardiomyopathy resulting from deposition of misfolded immunoglobulin light chains (AL-CA) or transthyretin (ATTR-CA) proteins in the myocardium. Survival varies between the different subtypes of amyloidosis and degree of cardiac involvement, but accurate diagnosis is essential to ensure initiation of therapeutic interventions that may slow or potentially prevent morbidity and mortality in these patients. As there are now effective treatment options for CA, identifying underlying disease pathogenesis is crucial and can be guided by multimodality imaging techniques such as echocardiography, magnetic resonance imaging, and nuclear scanning modalities. However, as use of cardiac imaging is becoming more widespread, understanding optimal applications and potential shortcomings is increasingly important. Additionally, certain imaging modalities can provide prognostic information and may affect treatment planning. In patients whom imaging remains non-diagnostic, tissue biopsy, specifically endomyocardial biopsy, continues to play an essential role and can facilitate accurate and timely diagnosis such that appropriate treatment can be started. In this review, we examine the multimodality imaging approach to the diagnosis of CA with particular emphasis on the prognostic utility and limitations of each imaging modality. We also discuss how imaging can guide the decision to pursue tissue biopsy for timely diagnosis of CA.
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Saad JM, Ahmed AI, Anugula D, Han Y, Alfawara MS, Al-Mallah MH. It Takes a Village: Multimodality Imaging of Cardiac Amyloidosis. Methodist Debakey Cardiovasc J 2022; 18:47-58. [PMID: 35414854 PMCID: PMC8932383 DOI: 10.14797/mdcvj.1072] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/17/2022] [Indexed: 11/26/2022] Open
Abstract
Cardiac amyloidosis (CA) is the buildup and infiltration of amyloid plaque in cardiac muscle. An underdiagnosed form of restrictive cardiomyopathy, CA can rapidly progress into heart failure. CA is evaluated using a multimodality approach that includes echocardiography, cardiac magnetic imaging, and nuclear imaging. Echocardiography remains an essential first-line modality that raises suspicion for CA and establishes functional baselines. Cardiac magnetic imaging provides additional incremental value via high-resolution imaging, robust functional assessment, and superior tissue characterization, all of which enable a more comprehensive investigation of CA. Cardiac scintigraphy has eliminated the need for invasive diagnostic approaches and helps differentiate CA subtypes. Positron emission tomography is the first modality introducing targeted amyloid binding tracers that allow for precise burden quantification, early detection, and disease monitoring. In this review, we highlight the role of several cardiac imaging techniques in the evaluation of CA.
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Affiliation(s)
- Jean Michel Saad
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, US
| | - Ahmed Ibrahim Ahmed
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, US
| | - Dixitha Anugula
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, US
| | - Yushui Han
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, US
| | - Moath Said Alfawara
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, US
| | - Mouaz H Al-Mallah
- Houston Methodist DeBakey Heart & Vascular Center, Houston Methodist Hospital, Houston, Texas, US
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40
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Ross JC, Hutt DF, Burniston M, Grigore SF, Fontana M, Page J, Hawkins PN, Gilbertson JA, Rowczenio D, Gillmore JD. The role of serial 99mTc-DPD scintigraphy in monitoring cardiac transthyretin amyloidosis. Amyloid 2022; 29:38-49. [PMID: 34704883 DOI: 10.1080/13506129.2021.1991302] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE Cardiac transthyretin amyloidosis is a usually fatal form of restrictive cardiomyopathy for which clinical trials of treatments are ongoing. It is anticipated that quantitative nuclear medicine scintigraphy, which is experiencing growing interest, will soon be used to evaluate treatment efficacy. We investigated its utility for monitoring changes in disease load over a significant time period. METHODS Sixty-two treatment-naive patients underwent 99mTc-labelled 3,3-diphosphono-1,2propanodicarboxylic acid (99mTc-DPD) scintigraphy two to four times each over a five-year period. Quantitation of cardiac 99mTc-DPD retention was performed according to two established methods: measurement of heart-to-contralateral ratio (H/CL) in the anterior view (planar) and percentage of administered activity in the myocardium (SPECT). RESULTS In total 170 datasets were analysed. Increased myocardial retention of 99mTc-DPD was demonstrable as early as 12 months from baseline. Year-on-year progression across the cohort was observed using SPECT-based quantitation, though on 30 occasions (27.8%) the change in our estimate was negative. CONCLUSIONS The spread of our results was notably high compared to the year-on-year increases. If left unaccounted for, variance may draw fallacious conclusions about changes in disease load. We therefore urge caution in drawing conclusions solely from nuclear medicine scintigraphy on a patient-by-patient basis, particularly across a short time period.
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Affiliation(s)
- James C Ross
- Division of Medicine (Royal Free Campus), Centre for Amyloidosis and Acute Phase Proteins, London, UK.,Department of Nuclear Medicine, Barts Health NHS Trust, London, UK
| | - David F Hutt
- Division of Medicine (Royal Free Campus), Centre for Amyloidosis and Acute Phase Proteins, London, UK
| | - Maria Burniston
- Division of Medicine (Royal Free Campus), Centre for Amyloidosis and Acute Phase Proteins, London, UK.,Department of Nuclear Medicine, Barts Health NHS Trust, London, UK
| | - Simona F Grigore
- Division of Medicine (Royal Free Campus), Centre for Amyloidosis and Acute Phase Proteins, London, UK
| | - Marianna Fontana
- Division of Medicine (Royal Free Campus), Centre for Amyloidosis and Acute Phase Proteins, London, UK
| | - Joanne Page
- Division of Medicine (Royal Free Campus), Centre for Amyloidosis and Acute Phase Proteins, London, UK.,Department of Nuclear Medicine, Royal Free London, NHS Foundation Trust, London, UK
| | - Philip N Hawkins
- Division of Medicine (Royal Free Campus), Centre for Amyloidosis and Acute Phase Proteins, London, UK
| | - Janet A Gilbertson
- Division of Medicine (Royal Free Campus), Centre for Amyloidosis and Acute Phase Proteins, London, UK
| | - Dorota Rowczenio
- Division of Medicine (Royal Free Campus), Centre for Amyloidosis and Acute Phase Proteins, London, UK
| | - Julian D Gillmore
- Division of Medicine (Royal Free Campus), Centre for Amyloidosis and Acute Phase Proteins, London, UK
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Law S, Petrie A, Chacko L, Cohen OC, Ravichandran S, Gilbertson JA, Rowczenio D, Wechalekar AD, Martinez-Naharro A, Lachmann HJ, Whelan CJ, Hutt DF, Hawkins PN, Fontana M, Gillmore JD. Change in N-terminal pro-B-type natriuretic peptide at 1 year predicts mortality in wild-type transthyretin amyloid cardiomyopathy. Heart 2022; 108:474-478. [PMID: 33990410 PMCID: PMC8899483 DOI: 10.1136/heartjnl-2021-319063] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Revised: 04/15/2021] [Accepted: 04/20/2021] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES Wild-type transthyretin amyloid cardiomyopathy (wtATTR-CM) is a progressive and fatal condition. Although prognosis can be determined at the time of diagnosis according to National Amyloidosis Centre (NAC) transthyretin amyloidosis (ATTR) stage, the clinical course varies substantially between individuals. There are currently no established measures of rate of disease progression. Through systematic analysis of functional, biochemical and echocardiographic disease-related variables we aimed to identify prognostic markers of disease progression in wtATTR-CM. METHODS This is a retrospective observational study of 432 patients with wtATTR-CM diagnosed at the UK NAC, none of whom received disease-modifying therapy. The association between mortality from the 12-month timepoint and change from diagnosis to 12 months in a variety of disease-related variables was explored using Cox regression. RESULTS Change in N-terminal pro-B-type natriuretic peptide concentration (∆ NT-proBNP) at 12 months from diagnosis was the strongest predictor of ongoing mortality and was independent of both change in other disease-related variables (HR 1.04 per 500 ng/L increase (95% CI 1.01 to 1.07); p=0.003) and a range of known prognostic variables at the time of diagnosis (HR 1.07 per 500 ng/L increase (95% CI 1.02 to 1.13); p=0.007). An increase in NT-proBNP of >500 ng/L, >1000 ng/L and >2000 ng/L during the first year of follow-up occurred in 45%, 35% and 16% of patients, respectively. CONCLUSION Change in NT-proBNP concentration during the first year of follow-up is a powerful independent predictor of mortality in wtATTR-CM.
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Affiliation(s)
- Steven Law
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Aviva Petrie
- Eastman Dental Institute, University College London, London, UK
| | - Liza Chacko
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Oliver C Cohen
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Sriram Ravichandran
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Janet A Gilbertson
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Dorota Rowczenio
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Ashutosh D Wechalekar
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Ana Martinez-Naharro
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Helen J Lachmann
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Carol J Whelan
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - David F Hutt
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Philip N Hawkins
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
| | - Julian D Gillmore
- National Amyloidosis Centre, Division of Medicine, University College London, London, UK
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Awareness of Nuclear Medicine Physicians in Romania Regarding the Diagnostic of Cardiac Amyloidosis—A Survey-Based Study. Diagnostics (Basel) 2022; 12:diagnostics12020556. [PMID: 35204645 PMCID: PMC8870760 DOI: 10.3390/diagnostics12020556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 02/17/2022] [Accepted: 02/18/2022] [Indexed: 11/16/2022] Open
Abstract
Amyloidosis is a heterogeneous group of diseases caused by the extracellular deposition of amyloid insoluble fibrils in multiple organs, resulting in various clinical manifestations. Cardiac amyloidosis (CA) occurs mainly in primary light-chain (AL) amyloidosis, hereditary transthyretin (ATTRv) amyloidosis and senile or wild-type transthyretin (ATTRwt) amyloidosis. Knowing that myocardial uptake at bone scintigraphy is an essential step in the ATTR-CA diagnostic algorithm, the level of awareness among nuclear medicine physicians (NMPs) using bone tracer scintigraphy is of great importance. The objective of the study was to evaluate NMPs’ awareness of scintigraphy with bisphosphonates for the detection of CA. We conducted an online survey among NMPs from Romania to assess their current awareness and state of knowledge of nuclear techniques used in CA. Among the total 65 Romanian NMPs, 35 (53%) responded to this questionnaire. Approximately three-quarters of participants (74%) found a diffuse accumulation of bisphosphonates in the heart on scintigraphy performed for bone pathology as an incidental discovery. Detection of myocardial uptake of 99mTc-labeled bisphosphonates on scintigraphy suggests CA-AL for 3% of participants and for 9% of respondents, the appearance is of uncertain cardiac amyloidosis, while 5% of participants observed cardiac uptake but did not report it as CA. Even if more than half of those who responded to this survey (54%) found abnormal cardiac uptake and interpreted it as CA-ATTR, only 14% contacted the referring physician to draw attention to the incidental discovery to refer the patient to a specialist in rare genetic cardiomyopathy. Regarding the knowledge about the categories of bisphosphonates recommended in the diagnosis of CA-ATTR, 54% answered inadequately that methylene diphosphonate (MDP) could be used. Romanian nuclear physicians are partially familiar with CA diagnosis by scintigraphy, but its diagnostic potential and standardization, recommended radiotracers and acquisition times and interpretation algorithms are known in varying proportions. Therefore, there is a need to enhance knowledge through continuing medical education programs in order to standardize the protocols for the acquisition, processing and interpretation of bisphosphonate scintigraphy for the detection of cardiac ATTR amyloidosis.
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Joury A, Faaborg-Andersen C, Quintana RA, daSilva-deAbreu A, Nativi-Nicolau J. Diagnostic Tools for Cardiac Amyloidosis: A Pragmatic Comparison of Pathology, Imaging and Laboratories. Curr Probl Cardiol 2022; 48:101106. [PMID: 35007639 DOI: 10.1016/j.cpcardiol.2022.101106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 01/03/2022] [Indexed: 01/01/2023]
Abstract
Cardiac amyloidosis (CA) is a complex disease considered to be the most common underdiagnosed form of restrictive cardiomyopathy. Accumulation of misfolded proteins called amyloid fibrils in the extracellular space results in clinical deterioration and late diagnosis is associated with morbidity and mortality. Both types of this disease, light chain CA and transthyretin-related CA share many cardiac and extracardiac features that compromise multiple organs such as kidneys, musculoskeletal system, autonomic nervous system, and gastrointestinal tract. Early diagnosis and detection of CA are imperative. Clinicians should maintain a high degree of suspicion among patients with unexplained diastolic heart failure to implement different disease-altering therapies at the early stages of the disease. In this article, we provided a comprehensive review of multiple invasive and non-invasive cardiac imaging modalities with their respective degrees of sensitivities and specificity.
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Affiliation(s)
- Abdulaziz Joury
- John Ochsner Heart and Vascular Institute, Ochsner Medical Center, New Orleans, LA; King Salman Heart Center, King Fahd Medical City, Riyadh, Saudi Arabia
| | | | - Raymundo A Quintana
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA
| | - Adrian daSilva-deAbreu
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT; Heart and Vascular Center, Yale-New Haven Hospital, New Haven, CT
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Zampieri M, Argirò A, Allinovi M, Tassetti L, Zocchi C, Gabriele M, Andrei V, Fumagalli C, Di Mario C, Tomberli A, Olivotto I, Perfetto F, Cappelli F. Sex-related differences in clinical presentation and all-cause mortality in patients with cardiac transthyretin amyloidosis and light chain amyloidosis. Int J Cardiol 2022; 351:71-77. [PMID: 34990715 DOI: 10.1016/j.ijcard.2021.12.048] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 12/24/2021] [Accepted: 12/28/2021] [Indexed: 01/06/2023]
Abstract
We aimed to ascertain whether sex-related differences are relevant to clinical presentation, cardiac phenotype and all-cause mortality in different types of cardiac amyloidosis, a field still poorly investigated. Medical files from consecutive patients diagnosed with cardiac amyloidosis between 2000 and 2020, at Careggi University Hospital, were retrospectively evaluated. Over this period, 259 patients (12% females) were diagnosed with wild type transthyretin amyloidosis (wtATTR), 52 (25% females) with hereditary transthyretin amyloidosis (hATTR) and 143 (47% females) with light chain amyloidosis (AL). Women with wtATTR, compared to men, were significantly older at the time of diagnosis and showed higher National Amyloidosis Centre score, thicker normalized interventricular septum, higher diastolic dysfunction and worse right ventricular function. Females with hATTR and AL had lower normalized cardiac mass compared to men, otherwise, bio-humoral parameters, NYHA class, and ECG characteristics were similar. Comparing females and male with wtATTR, hATTR and AL, no differences in Kaplan-Meier curves for all-cause mortality were observed with regard to sex, p-value >0.05. In conclusion, we did not observe major differences in clinical expression related to sex in different types of cardiac amyloidosis: specifically, all-cause mortality was not affected. Nevertheless, women with wtATTR had echocardiographic signs of more advanced disease and higher NAC score at diagnosis suggesting a possible later recognition of disease compared to men.
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Affiliation(s)
- Mattia Zampieri
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy; Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Alessia Argirò
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy; Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy.
| | - Marco Allinovi
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Luigi Tassetti
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy; Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Chiara Zocchi
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy; Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Martina Gabriele
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Valentina Andrei
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy
| | - Carlo Fumagalli
- Geriatric Cardiology, Careggi University Hospital, Florence, Italy
| | - Carlo Di Mario
- Division of Interventional Structural Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Alessia Tomberli
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Iacopo Olivotto
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Federico Perfetto
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy; IV Internal Medicine Division, Careggi University Hospital, Florence, Italy
| | - Francesco Cappelli
- Tuscan Regional Amyloidosis Centre, Careggi University Hospital, Florence, Italy; Division of Interventional Structural Cardiology, Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
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45
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Butt EJ, Boyars MC. An Unusual Case of Heart Failure: Sometimes When You Hear Hoof Beats You Should Think of Zebras. Cureus 2021; 13:e20801. [PMID: 35141062 PMCID: PMC8796951 DOI: 10.7759/cureus.20801] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2021] [Indexed: 11/07/2022] Open
Abstract
This case describes a 74-year-old male who was hospitalized with hyponatremia and worsening systolic and new diastolic heart failure. Workup showed low voltage QRS complexes on electrocardiogram and new diastolic dysfunction on echocardiogram. Because of this clinical scenario amyloidosis was suspected. ATTR amyloidosis was confirmed without doing an invasive endocardial biopsy by the use of immunofixation studies and Technetium 99 PYPm scan, and abdominal fat pad biopsy. The types and manifestations of amyloidosis in general and cardiac amyloidosis, in particular, are reviewed as well as the diagnostic test available to the clinician to confirm this diagnosis.
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Affiliation(s)
- Edward J Butt
- Internal Medicine, University of Texas Medical Branch, Galveston, USA
| | - Michael C Boyars
- Internal Medicine, University of Texas Medical Branch, Galveston, USA
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46
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Korosoglou G, Giusca S, André F, Aus dem Siepen F, Nunninger P, Kristen AV, Frey N. Diagnostic Work-Up of Cardiac Amyloidosis Using Cardiovascular Imaging: Current Standards and Practical Algorithms. Vasc Health Risk Manag 2021; 17:661-673. [PMID: 34720583 PMCID: PMC8550552 DOI: 10.2147/vhrm.s295376] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 10/07/2021] [Indexed: 01/15/2023] Open
Abstract
Among non-ischemic cardiomyopathies, cardiac amyloidosis is one of the most common, being caused by extracellular depositions of amyloid fibrils in the myocardium. Two main forms of cardiac amyloidosis are known so far, including 1) light-chain (AL) amyloidosis caused by monoclonal production of light-chains, and 2) transthyretin (ATTR) amyloidosis, caused by dissociation of the transthyretin tetramer into monomers. Both AL and ATTR amyloidosis are progressive diseases with median survival from diagnosis of less than 6 months and 3 to 5 years, respectively, if untreated. In this regard, death occurs in most patients due to cardiac causes, mainly congestive heart failure, which can be prevented due to the presence of effective, life-saving treatment regimens. Therefore, early diagnosis of cardiac amyloidosis is crucial more than ever. However, diagnosis of cardiac amyloidosis may be challenging due to variable clinical manifestations and the perceived rarity of the disease. In this regard, clinical and laboratory reg flags are available, which may help clinicians to raise suspicion of cardiac amyloidosis. In addition, advances in cardiovascular imaging have already revealed a higher prevalence of cardiac amyloidosis in specific populations, so that the diagnosis especially of ATTR amyloidosis has experienced a >30-fold increase during the past ten years. The goal of our review article is to summarize these findings and provide a practical approach for clinicians on how to use cardiovascular imaging techniques, such as echocardiography, cardiac magnetic resonance, bone scintigraphy and, if required, organ biopsy within predefined diagnostic algorithms for the diagnostic work-up of patients with suspected cardiac amyloidosis. In addition, two clinical cases and practical tips are provided in this context.
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Affiliation(s)
- Grigorios Korosoglou
- GRN Hospital Weinheim, Department of Cardiology, Vascular Medicine and Pneumology, Weinheim, Germany.,Cardiac Imaging Center Weinheim, Hector Foundation, Weinheim, Germany
| | - Sorin Giusca
- GRN Hospital Weinheim, Department of Cardiology, Vascular Medicine and Pneumology, Weinheim, Germany.,Cardiac Imaging Center Weinheim, Hector Foundation, Weinheim, Germany
| | - Florian André
- Department of Cardiology, Pneumology and Angiology, University Hospital Heidelberg, Heidelberg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Heidelberg, Heidelberg, Germany
| | - Fabian Aus dem Siepen
- Department of Cardiology, Pneumology and Angiology, University Hospital Heidelberg, Heidelberg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Heidelberg, Heidelberg, Germany
| | | | - Arnt V Kristen
- Department of Cardiology, Pneumology and Angiology, University Hospital Heidelberg, Heidelberg, Germany.,Cardiovascular Center Darmstadt, Darmstadt, Germany
| | - Norbert Frey
- Department of Cardiology, Pneumology and Angiology, University Hospital Heidelberg, Heidelberg, Germany.,German Centre for Cardiovascular Research (DZHK), Partner Site Heidelberg, Heidelberg, Germany
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47
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99mTechnetium-labeled cardiac scintigraphy for suspected amyloidosis: a review of current and future directions. Heart Fail Rev 2021; 27:1493-1503. [PMID: 34709500 DOI: 10.1007/s10741-021-10174-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/16/2021] [Indexed: 10/20/2022]
Abstract
Cardiac amyloidosis (CA) is an underdiagnosed form of restrictive cardiomyopathy leading to a rapid progression into heart failure. Evaluation of CA requires a multimodality approach making use of echocardiography, cardiac magnetic imaging, and nuclear imaging. Technetium (Tc)-labeled cardiac scintigraphy has witnessed a resurgence in its application for the workup of CA. Advancements in disease-modifying therapies have fueled the rapid adoption of cardiac scintigraphy using bone tracers and the need for transformative novel studies. The goal of this review is to present diagnostic utility, currently recommended protocols, as well as a glimpse into the rapid evolution of Tc-labeled cardiac scintigraphy in the diagnosis of CA.
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48
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Wu Z, Yu C. Diagnostic performance of CMR, SPECT, and PET imaging for the detection of cardiac amyloidosis: a meta-analysis. BMC Cardiovasc Disord 2021; 21:482. [PMID: 34620092 PMCID: PMC8499558 DOI: 10.1186/s12872-021-02292-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 09/17/2021] [Indexed: 12/24/2022] Open
Abstract
Background Noninvasive myocardial imaging modalities, such as cardiac magnetic resonance (CMR), single photon emission computed tomography (SPECT), and Positron emission tomography (PET), are well-established and extensively used to detect cardiac amyloid (CA). The purpose of this study is to directly compare CMR, SPECT, and PET scans in the diagnosis of CA, and to provide evidence for further scientific research and clinical decision-making. Methods PubMed, Embase, and Cochrane Library were searched. Studies used CMR, SPECT and/or PET for the diagnosis of CA were included. Pooled sensitivity, specificity, positive and negative likelihood ratio (LR), diagnostic odds ratio (DOR), their respective 95% confidence intervals (CIs) and the area under the summary receiver operating characteristic (SROC) curve (AUC) were calculated. Quality assessment of included studies was conducted. Results A total of 31 articles were identified for inclusion in this meta-analysis. The pooled sensitivities of CMR, SPECT and PET were 0.84, 0.98 and 0.78, respectively. Their respective overall specificities were 0.87, 0.92 and 0.95. Subgroup analysis demonstrated that 99mTc-HMDP manifested the highest sensitivity (0.99). 99mTc-PYP had the highest specificity (0.95). The AUC values of 99mTc-DPD, 99mTc-PYP, 99mTc-HMDP were 0.89, 0.99, and 0.99, respectively. PET scan with 11C-PIB demonstrated a pooled sensitivity of 0.91 and specificity of 0.97 with an AUC value of 0.98. Conclusion Our meta-analysis reveals that SEPCT scans present better diagnostic performance for the identification of CA as compared with other two modalities. Supplementary Information The online version contains supplementary material available at 10.1186/s12872-021-02292-z.
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Affiliation(s)
- Zhaoye Wu
- Department of Nuclear Medicine, Affiliated Hospital of Jiangnan University, Wuxi, China
| | - Chunjing Yu
- Department of Nuclear Medicine, Affiliated Hospital of Jiangnan University, Wuxi, China.
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49
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Adams D, Algalarrondo V, Polydefkis M, Sarswat N, Slama MS, Nativi-Nicolau J. Expert opinion on monitoring symptomatic hereditary transthyretin-mediated amyloidosis and assessment of disease progression. Orphanet J Rare Dis 2021; 16:411. [PMID: 34602081 PMCID: PMC8489116 DOI: 10.1186/s13023-021-01960-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Accepted: 07/18/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Hereditary transthyretin-mediated amyloidosis, also known as ATTRv amyloidosis (v for variant), is a rare, autosomal dominant, fatal disease, in which systemic amyloid progressively impairs multiple organs, leading to disability and death. The recent approval of disease-modifying therapies offers the hope of stabilization or eventual reversal of disease progression, and yet highlights a lack of disease-management guidance. A multidisciplinary panel of expert clinicians from France and the US came to consensus on monitoring the disease and identifying progression through a clinical opinion questionnaire, a roundtable meeting, and multiple rounds of feedback. MONITORING DISEASE AND PROGRESSION A multidisciplinary team should monitor ATTRv amyloidosis disease course by assessing potential target organs at baseline and during follow-up for signs and symptoms of somatic and autonomic neuropathy, cardiac dysfunction and restrictive cardiomyopathy, and other manifestations. Variability in penetrance, symptoms, and course of ATTRv amyloidosis requires that all patients, regardless of variant status, undergo regular and standardized assessment in all these categories. Progression in ATTRv amyloidosis may be indicated by: worsening of several existing quantifiable symptoms or signs; the appearance of a new symptom; or the worsening of a single symptom that results in a meaningful functional impairment. CONCLUSIONS We suggest that a multisystem approach to monitoring the signs and symptoms of ATTRv amyloidosis best captures the course of the disease. We hope this work will help form the basis of further, consensus-based guidance for the treatment of ATTRv amyloidosis.
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Affiliation(s)
- David Adams
- Université Paris-Saclay, U1195, INSERM, Le Kremlin Bicêtre, France
- Neurology Department, AP-HP, CHU Bicêtre, Le Kremlin Bicêtre, France
| | - Vincent Algalarrondo
- Cardiology Department, CHU Bichat-Claude-Bernard, 46 rue Henri Huchard, 75018, Paris, France
| | - Michael Polydefkis
- Department of Neurology, Johns Hopkins Hospital, 855 North Wolfe Street, Baltimore, MD, 21205, USA
| | - Nitasha Sarswat
- Department of Medicine, University of Chicago, 5841 S Maryland Ave, Chicago, IL, 60637, USA
| | - Michel S Slama
- Cardiology Department, CHU Bichat-Claude-Bernard, 46 rue Henri Huchard, 75018, Paris, France
| | - Jose Nativi-Nicolau
- Department of Internal Medicine, University of Utah, 30 N 1900 E, Salt Lake City, UT, 84132, USA.
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50
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Minutoli F, Di Bella G, Mazzeo A, Laudicella R, Gentile L, Russo M, Vita G, Baldari S. Serial scanning with 99mTc-3, 3-diphosphono-1, 2-propanodicarboxylic acid ( 99mTc-DPD) for early detection of cardiac amyloid deposition and prediction of clinical worsening in subjects carrying a transthyretin gene mutation. J Nucl Cardiol 2021; 28:1949-1957. [PMID: 31741327 DOI: 10.1007/s12350-019-01950-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2019] [Accepted: 10/07/2019] [Indexed: 01/18/2023]
Abstract
BACKGROUND To determine the capability of 99mTc-DPD scintigraphy to detect early cardiac involvement and predict clinical worsening in transthyretin (TTR) gene mutation patients. METHODS Eleven mutated subjects with normal interventricular septum (IVS) thickness, NT-proBNP level and no cardiac symptoms underwent three seriate 99mTc-DPD scans (visually and semiquantitatively analyzed), and was followed-up for 5-8-years. RESULTS Six patients showed no myocardial accumulation in all scans. Increased IVS thickness occurring in one patient 4 years after the last scan was the only abnormal finding in these patients; no cardiac symptoms developed during the follow-up. In three patients, cardiac radiotracer uptake was found at enrollment; other laboratory/instrumental abnormal findings occurred later and cardiac symptoms developed during the follow-up period. Two patients had a negative 99mTc-DPD scan at enrollment and showed cardiac uptake in the following scans. Increased mean left-ventricular (LV) wall thickness was found 3 years after positive scintigraphy; NT-proBNP increased later in one patient. These patients developed cardiac symptoms during the follow-up period. CONCLUSIONS 99mTc-DPD scan detects cardiac involvement in subjects with TTR gene mutation earlier than ECG, echocardiography and biochemical markers, occurring some years before the fulfillment of current diagnostic criteria for cardiac amyloidosis. A positive 99mTc-DPD scan predicts cardiac symptoms onset.
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Affiliation(s)
- F Minutoli
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, University Hospital "G. Martino", Via Consolare Valeria 1, 98125, Messina, Italy
| | - G Di Bella
- Department of Clinical and Experimental Medicine, University of Messina, University Hospital "G. Martino", Via Consolare Valeria 1, 98125, Messina, Italy
| | - A Mazzeo
- Department of Clinical and Experimental Medicine, University of Messina, University Hospital "G. Martino", Via Consolare Valeria 1, 98125, Messina, Italy
| | - R Laudicella
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, University Hospital "G. Martino", Via Consolare Valeria 1, 98125, Messina, Italy.
| | - L Gentile
- Department of Clinical and Experimental Medicine, University of Messina, University Hospital "G. Martino", Via Consolare Valeria 1, 98125, Messina, Italy
| | - M Russo
- Nemo Sud Clinical Centre, University Hospital "G. Martino", Messina, Italy
| | - G Vita
- Department of Clinical and Experimental Medicine, University of Messina, University Hospital "G. Martino", Via Consolare Valeria 1, 98125, Messina, Italy
| | - S Baldari
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, University Hospital "G. Martino", Via Consolare Valeria 1, 98125, Messina, Italy
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