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Singulane C, Sun D, Hu Z, Lee L, Sarswat N, Emami Neyestanak M, Patel AR, Lang RM, Addetia K. Defining echocardiographic predictors of outcome in cardiac amyloidosis by subtype. Curr Probl Cardiol 2024; 49:102729. [PMID: 38945183 DOI: 10.1016/j.cpcardiol.2024.102729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2024] [Accepted: 06/26/2024] [Indexed: 07/02/2024]
Abstract
BACKGROUND Current echocardiographic risk factors for prognosis in cardiac amyloidosis (CA) do not distinguish between the two main subtypes: transthyretin cardiomyopathy (TTR) and immunoglobulin light chain cardiomyopathy (AL), each of which require distinct diagnostic and therapeutic approaches. Additionally, only traditional parameters have been studied with little data on advanced techniques. Accordingly, we sought to determine whether differences exist in 2D transthoracic echocardiography (2DE) predictors of survival between the CA subtypes using a comprehensive approach. METHODS 220 patients (72±12 years) with confirmed CA (AL=89, TTR=131) who underwent 2DE at the time of CA diagnosis were enrolled. Left ventricular (LV) dimensions, indexed mass (LVMi), global longitudinal strain (LVGLS), apical-sparing ratio (LVASR), diastology, right ventricular (RV) size and function indices including tricuspid annular systolic excursion (TAPSE), RV free-wall (RVFWS) and global (RVGLS) strain, indexed left (LA) and right atrial volumes (LAVi and RAVi), LA strain (reservoir and booster) and RV systolic pressure (RVSP) were measured. A propensity-score weighted stepwise variable selection Cox proportional hazards model derived from NYHA class and renal impairment status at diagnosis was used to determine the associations between 2DE parameters and mortality specific to CA subtype over a median follow-up of 36-months. RESULTS After adjusting for age, atrial fibrillation and treatment, parameters associated with survival were RVFWS (p=0.003, HR 1.15, 95% CI[1.053,1.245]) and RVSP (p=0.03, HR 1.03, 95% CI[1.004,1.063]) in AL and LVASR (p=0.007, HR 6.68, 95% CI[1.75,25.492]) and RAVi (p=0.049, HR 1.03, 95% CI[1.000,1.052]) in TTR. CONCLUSIONS Echocardiographic prognosticators for survival are specific to cardiac amyloid subtype. These results potentially provide information critical for clinical decision-making and follow-up in these patients.
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Affiliation(s)
- Cristiane Singulane
- University of Chicago, Department of Medicine, Section of Cardiology, Chicago, IL, USA
| | - Deyu Sun
- University of Chicago, Department of Medicine, Section of Cardiology, Chicago, IL, USA
| | - Zhen Hu
- University of Chicago, Department of Medicine, Section of Cardiology, Chicago, IL, USA
| | - Linda Lee
- University of Chicago, Department of Medicine, Section of Cardiology, Chicago, IL, USA
| | - Nitasha Sarswat
- University of Chicago, Department of Medicine, Section of Cardiology, Chicago, IL, USA
| | | | - Amit R Patel
- University of Chicago, Department of Medicine, Section of Cardiology, Chicago, IL, USA
| | - Roberto M Lang
- University of Chicago, Department of Medicine, Section of Cardiology, Chicago, IL, USA
| | - Karima Addetia
- University of Chicago, Department of Medicine, Section of Cardiology, Chicago, IL, USA.
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Herrador L, Yun S, González-Costello J. Update in 'wild-type' transthyretin cardiac amyloidosis: Clinical guide for its diagnosis and treatment. Med Clin (Barc) 2024; 163:e36-e43. [PMID: 38762347 DOI: 10.1016/j.medcli.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2023] [Revised: 03/06/2024] [Accepted: 03/07/2024] [Indexed: 05/20/2024]
Affiliation(s)
- Lorena Herrador
- Unidad de Insuficiencia Cardíaca Avanzada y Trasplante Cardíaco, Servicio de Cardiología, Hospital Universitario de Bellvitge, Hospitalet de Llobregat, Barcelona, España; Bio-Heart, grupo de investigación en enfermedades cardiovasculares, Instituto de Investigación Biomédica de Bellvitge, Hospitalet de Llobregat, Barcelona, España
| | - Sergi Yun
- Bio-Heart, grupo de investigación en enfermedades cardiovasculares, Instituto de Investigación Biomédica de Bellvitge, Hospitalet de Llobregat, Barcelona, España; Unidad de Insuficiencia Cardíaca Comunitaria, Servicio de Medicina Interna, Hospital Universitario de Bellvitge, Hospitalet de Llobregat, Barcelona, España; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Instituto CarlosIII, Madrid, España
| | - José González-Costello
- Unidad de Insuficiencia Cardíaca Avanzada y Trasplante Cardíaco, Servicio de Cardiología, Hospital Universitario de Bellvitge, Hospitalet de Llobregat, Barcelona, España; Bio-Heart, grupo de investigación en enfermedades cardiovasculares, Instituto de Investigación Biomédica de Bellvitge, Hospitalet de Llobregat, Barcelona, España; Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Instituto CarlosIII, Madrid, España; Departamento de Ciencias Clínicas, Facultad de Medicina y Ciencias de la Salud, Universidad de Barcelona, Barcelona, España.
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3
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Maccallini M, Barge-Caballero G, Barge-Caballero E, López-Pérez M, Bilbao-Quesada R, González-Babarro E, Gómez-Otero I, López-López A, Gutiérrez-Feijoo M, Varela-Román A, García-Seara J, Bouzas-Mosquera A, Crespo-Leiro MG. Prognostic value of the tricuspid annular plane systolic excursion/systolic pulmonary artery pressure ratio in cardiac amyloidosis. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:634-644. [PMID: 38296161 DOI: 10.1016/j.rec.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 01/05/2024] [Indexed: 02/19/2024]
Abstract
INTRODUCTION AND OBJECTIVES The tricuspid annular plane systolic excursion/systolic pulmonary artery pressure (TAPSE/SPAP) ratio is a noninvasive surrogate of right ventricular to pulmonary circulation that has prognostic implications in patients with heart failure (HF) or pulmonary hypertension. Our purpose was to evaluate the prognostic value of the TAPSE/SPAP ratio in patients with cardiac amyloidosis. METHODS We used the database of the AMIGAL study, a prospective, observational registry of patients with cardiac amyloidosis recruited in 7 hospitals of the Autonomous Community of Galicia, Spain, from January 1, 2018 to October 31, 2022. We selected patients whose baseline TAPSE/SPAP ratio was calculated with transthoracic echocardiography. Long-term survival and survival free of HF hospitalization were assessed by means of 5 different multivariable Cox regression models. Median follow-up was 680 days. RESULTS We studied 233 patients with cardiac amyloidosis, among whom 209 (89.7%) had transthyretin type. The baseline TAPSE/SPAP ratio correlated significantly with clinical outcomes. Depending on the multivariable model considered, the adjusted hazard ratios estimated per 0.1mm/mmHg increase of baseline TAPSE/SPAP ratio ranged from 0.76 to 0.84 for all-cause mortality. Similarly, the ratios for all-cause mortality of HF hospitalization ranged from 0.79 to 0.84. The addition of the baseline TAPSE/SPAP ratio to the predictive model of the United Kingdom National Amyloidosis Centre resulted in an increase in Harrell's c-statistic from 0.662 to 0.705 for all-cause mortality and from 0.668 to 0.707 for all-cause mortality or HF hospitalization. CONCLUSIONS Reduced TAPSE/SPAP ratio is an independent adverse prognostic marker in patients with cardiac amyloidosis.
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Affiliation(s)
- Marta Maccallini
- Department of Internal Medicine, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Gonzalo Barge-Caballero
- Servicio de Cardiología, Complexo Hospitalario Universitario A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), Servicio Galego de Saúde (SERGAS), A Coruña, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Eduardo Barge-Caballero
- Servicio de Cardiología, Complexo Hospitalario Universitario A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), Servicio Galego de Saúde (SERGAS), A Coruña, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.
| | - Manuel López-Pérez
- Servicio de Cardiología, Complexo Hospitalario Universitario de Ferrol (CHUF), Servicio Galego de Saúde (SERGAS), Ferrol, A Coruña, Spain
| | - Raquel Bilbao-Quesada
- Servicio de Cardiología, Complexo Hospitalario Universitario de Vigo (CHUVI), Servicio Galego de Saúde (SERGAS), Vigo, Pontevedra, Spain
| | - Eva González-Babarro
- Servicio de Cardiología, Complexo Hospitalario Universitario de Pontevedra (CHOP), Servicio Galego de Saúde (SERGAS), Pontevedra, Spain
| | - Inés Gómez-Otero
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS), Servicio Galego de Saúde (SERGAS), Santiago de Compostela, A Coruña, Spain
| | - Andrea López-López
- Servicio de Cardiología, Hospital Universitario Lucus Augusti (HULA), Servicio Galego de Saúde (SERGAS), Lugo, Spain
| | - Mario Gutiérrez-Feijoo
- Servicio de Cardiología, Complexo Hospitalario Universitario de Ourense (CHUOU), Servicio Galego de Saúde (SERGAS), Ourense, Spain
| | - Alfonso Varela-Román
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS), Servicio Galego de Saúde (SERGAS), Santiago de Compostela, A Coruña, Spain
| | - Javier García-Seara
- Servicio de Cardiología, Complexo Hospitalario Universitario de Santiago de Compostela (CHUS), Servicio Galego de Saúde (SERGAS), Santiago de Compostela, A Coruña, Spain
| | - Alberto Bouzas-Mosquera
- Servicio de Cardiología, Complexo Hospitalario Universitario A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), Servicio Galego de Saúde (SERGAS), A Coruña, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - María G Crespo-Leiro
- Servicio de Cardiología, Complexo Hospitalario Universitario A Coruña (CHUAC), Instituto de Investigación Biomédica de A Coruña (INIBIC), Servicio Galego de Saúde (SERGAS), A Coruña, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
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Hu M, Song Y, Yang C, Wang J, Zhu W, Kan A, Yang P, Dai J, Yu H, Gong L. The value of myocardial contraction fraction and long-axis strain to predict late gadolinium enhancement in multiple myeloma patients with secondary cardiac amyloidosis. Sci Rep 2024; 14:16832. [PMID: 39039146 PMCID: PMC11263677 DOI: 10.1038/s41598-024-67544-2] [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: 02/26/2024] [Accepted: 07/12/2024] [Indexed: 07/24/2024] Open
Abstract
The aim of this study is to assess the effectiveness of conventional and two additional functional markers derived from standard cardiac magnetic resonance (CMR) images in detecting the occurrence of late gadolinium enhancement (LGE) in patients with secondary cardiac amyloidosis (CA) related to multiple myeloma (MM). This study retrospectively included 32 patients with preserved ejection fraction (EF) who had MM-CA diagnosed consecutively. Conventional left ventricular (LV) function markers and two additional functional markers, namely myocardial contraction fraction (MCF) and LV long-axis strain (LAS), were obtained using commercial cardiac post-processing software. Logistic regression analyses and receiver operating characteristic (ROC) analysis were performed to evaluate the predictive performances. (1) There were no notable distinctions in clinical features between the LGE+ and LGE- groups, with the exception of a reduced systolic blood pressure in the former (105.60 ± 18.85 mmHg vs. 124.50 ± 20.95 mmHg, P = 0.022). (2) Patients with MM-CA presented with intractable heart failure with preserved ejection fraction (HFpEF). The LVEF in the LGE+ group exhibited a greater reduction (54.27%, IQR 51.59-58.39%) in comparison to the LGE- group (P < 0.05). And MM-CA patients with LGE+ had significantly higher LVMI (90.15 ± 23.69 g/m2), lower MCF (47.39%, IQR 34.28-54.90%), and the LV LAS were more severely damaged (- 9.94 ± 3.42%) than patients with LGE- (all P values < 0.05). (3) The study found that MCF exhibited a significant independent association with LGE, as indicated by an odds ratio of 0.89 (P < 0.05). The cut-off value for MCF was determined to be 64.25% with a 95% confidence interval ranging from 0.758 to 0.983. The sensitivity and specificity of this association were calculated to be 95% and 83%, respectively. MCF is a simple reproducible predict marker of LGE in MM-CA patients. It is a potentially CMR-based method that promise to reduce scan times and costs, and boost the accessibility of CMR.
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Affiliation(s)
- Mengyao Hu
- Department of Radiology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, No.1, Minde Road, Donghu District, Nanchang, Jiangxi, 330006, People's Republic of China
| | - Yipei Song
- Department of Radiology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, No.1, Minde Road, Donghu District, Nanchang, Jiangxi, 330006, People's Republic of China
| | - Chunhua Yang
- Department of Radiology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, No.1, Minde Road, Donghu District, Nanchang, Jiangxi, 330006, People's Republic of China
| | - Jiazhao Wang
- Department of Radiology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, No.1, Minde Road, Donghu District, Nanchang, Jiangxi, 330006, People's Republic of China
| | - Wei Zhu
- Department of Radiology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, No.1, Minde Road, Donghu District, Nanchang, Jiangxi, 330006, People's Republic of China
| | - Ao Kan
- Department of Radiology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, No.1, Minde Road, Donghu District, Nanchang, Jiangxi, 330006, People's Republic of China
| | - Pei Yang
- Department of Radiology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, No.1, Minde Road, Donghu District, Nanchang, Jiangxi, 330006, People's Republic of China
| | - Jiankun Dai
- Clinical and Technical Support, GE Healthcare, Beijing, People's Republic of China
| | - Honghui Yu
- Department of Radiology, The First Affiliated Hospital of Nanchang University, No.17, Yongwai Zheng Street, Donghu District, Nanchang, Jiangxi, 330006, People's Republic of China.
| | - Lianggeng Gong
- Department of Radiology, The Second Affiliated Hospital, Jiangxi Medical College, Nanchang University, No.1, Minde Road, Donghu District, Nanchang, Jiangxi, 330006, People's Republic of China.
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5
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Clerc OF, Datar Y, Cuddy SAM, Bianchi G, Taylor A, Benz DC, Robertson M, Kijewski MF, Jerosch-Herold M, Kwong RY, Ruberg FL, Liao R, Di Carli MF, Falk RH, Dorbala S. Prognostic Value of Left Ventricular 18F-Florbetapir Uptake in Systemic Light-Chain Amyloidosis. JACC Cardiovasc Imaging 2024:S1936-878X(24)00189-X. [PMID: 39001731 DOI: 10.1016/j.jcmg.2024.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Revised: 04/22/2024] [Accepted: 05/02/2024] [Indexed: 07/15/2024]
Abstract
BACKGROUND Positron emission tomography/computed tomography (PET/CT) with 18F-florbetapir, a novel amyloid-targeting radiotracer, can quantify left ventricular (LV) amyloid burden in systemic light-chain (AL) amyloidosis. However, its prognostic value is not known. OBJECTIVES The authors' aim was to evaluate the prognostic value of LV amyloid burden quantified by 18F-florbetapir PET/CT, and to identify mechanistic pathways mediating its association with outcomes. METHODS A total of 81 participants with newly diagnosed AL amyloidosis underwent 18F-florbetapir PET/CT imaging. Amyloid burden was quantified using 18F-florbetapir LV uptake as percent injected dose. The Mayo stage for AL amyloidosis was determined using troponin T, N-terminal pro-B-type natriuretic peptide (NT-proBNP), and free light chain levels. Major adverse cardiac events (MACE) were defined as all-cause death, heart failure hospitalization, or cardiac transplantation within 12 months. RESULTS Among participants (median age, 61 years; 57% males), 36% experienced MACE, increasing from 7% to 63% across tertiles of LV amyloid burden (P < 0.001). LV amyloid burden was associated with MACE (HR: 1.46; 95% CI: 1.16-1.83; P = 0.001). However, this association became nonsignificant when adjusted for Mayo stage. In mediation analysis, the association between LV amyloid burden and MACE was mediated by NT-proBNP (P < 0.001), a marker of cardiomyocyte stretch and heart failure, and a component of Mayo stage. CONCLUSIONS In this first study to link cardiac 18F-florbetapir uptake to subsequent outcomes, LV amyloid burden estimated by percent injected dose predicted MACE in AL amyloidosis. This effect was not independent of Mayo stage and was mediated primarily through NT-proBNP. These findings provide novel insights into the mechanism linking myocardial amyloid deposits to MACE.
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Affiliation(s)
- Olivier F Clerc
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Yesh Datar
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sarah A M Cuddy
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; CV Imaging Program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Giada Bianchi
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Hematology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Alexandra Taylor
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Dominik C Benz
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Matthew Robertson
- CV Imaging Program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Marie Foley Kijewski
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Michael Jerosch-Herold
- CV Imaging Program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Raymond Y Kwong
- CV Imaging Program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Frederick L Ruberg
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA; Section of Cardiovascular Medicine, Department of Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Ronglih Liao
- Amyloidosis Program, Stanford University, Stanford, California, USA
| | - Marcelo F Di Carli
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA; CV Imaging Program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Rodney H Falk
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sharmila Dorbala
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA; Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; CV Imaging Program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, Massachusetts, USA.
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Caobelli F, Gözlügöl N, Bakula A, Rominger A, Schepers R, Stortecky S, Hunziker Munsch L, Dobner S, Gräni C. Prognostic Value of [ 99mTc]Tc-DPD Quantitative SPECT/CT in Patients with Suspected and Confirmed Amyloid Transthyretin-Related Cardiomyopathy and Preserved Left Ventricular Function. J Nucl Med 2024; 65:944-951. [PMID: 38724281 DOI: 10.2967/jnumed.123.266926] [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: 10/24/2023] [Revised: 04/03/2024] [Indexed: 06/05/2024] Open
Abstract
Quantitative 99mTc-3,3-diphosphono-1,2-propanodicarboxylic acid ([99mTc]Tc-DPD) SPECT may be used for risk-stratifying patients with amyloid transthyretin-related cardiomyopathy (ATTR-CM). We aimed to analyze the predictive value of quantitative [99mTc]Tc-DPD SPECT/CT in suspected and confirmed ATTR-CM according to different disease stages. Methods: The study enrolled consecutive patients with suspected ATTR-CM who were referred to a single tertiary center and underwent quantitative [99mTc]Tc-DPD SPECT/CT allowing SUVmax and SUVpeak analysis. Patients were divided into 2 groups according to left ventricular ejection fraction (LVEF) at baseline (i.e., ≥50% and <50%). Clinical, laboratory, and echocardiographic parameters and major adverse cardiac events (i.e., all-cause death, sustained ventricular tachyarrhythmia, hospitalization for heart failure, implantation of a cardioverter defibrillator) were investigated for any correlation with quantitative uptake values. Results: In total, 144 patients with suspected ATTR-CM were included in the study (98 with LVEF ≥ 50% and 46 with LVEF < 50%), of whom 99 were diagnosed with ATTR-CM (68.8%; 69 with LVEF ≥ 50% and 30 with LVEF < 50%). A myocardial SUVmax of at least 7 was predictive of major adverse cardiac events at 21.9 ± 13.0 mo of follow-up (hazard ratio, 2.875; 95% CI, 1.23-6.71; P = 0.015) in patients with suspected or confirmed ATTR-CM (global χ2 = 6.892, P = 0.02) and an LVEF of at least 50%. SUVmax was not predictive in patients with an LVEF of less than 50% and suspected or confirmed ATTR-CM. Conclusion: In patients with suspected or confirmed ATTR-CM and preserved LVEF, representing an early disease stage, quantitative [99mTc]Tc-DPD SPECT should be considered to improve early-stage risk stratification.
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Affiliation(s)
- Federico Caobelli
- Department of Nuclear Medicine, Bern University Hospital, University of Bern, Bern, Switzerland;
| | - Nasir Gözlügöl
- Department of Nuclear Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Adam Bakula
- Department of Nuclear Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Axel Rominger
- Department of Nuclear Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Robin Schepers
- Department of Nuclear Medicine, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefan Stortecky
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland; and
| | - Lukas Hunziker Munsch
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland; and
| | - Stephan Dobner
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland; and
- Third Medical Department of Cardiology and Intensive Care Medicine, Clinic Ottakring, Vienna, Austria
| | - Christoph Gräni
- Department of Cardiology, Bern University Hospital, University of Bern, Bern, Switzerland; and
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Vogel J, Carpinteiro A, Luedike P, Buehning F, Wernhart S, Rassaf T, Michel L. Current Therapies and Future Horizons in Cardiac Amyloidosis Treatment. Curr Heart Fail Rep 2024:10.1007/s11897-024-00669-7. [PMID: 38809394 DOI: 10.1007/s11897-024-00669-7] [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: 05/20/2024] [Indexed: 05/30/2024]
Abstract
PURPOSE OF REVIEW Cardiac amyloidosis (CA) is a condition characterized by misfolding and extracellular deposition of proteins, leading to organ dysfunction. While numerous forms of CA exist, two subtypes dominate clinical prevalence: Transthyretin amyloid (ATTR) and immunoglobulin light chain amyloid. RECENT FINDINGS The current scientific landscape reflects the urgency to advance therapeutic interventions with over 100 ongoing clinical trials. Heart failure treatment is affected by CA phenotype with poor tolerance of otherwise frequently used medications. Treating comorbidities including atrial fibrillation and valvular disease remains a challenge in CA, driven by technical difficulties and uncertain outcomes. Tafamidis is the first ATTR-stabilizer approved with a rapidly growing rate of clinical use. In parallel, various new therapeutic classes are in late-stage clinical trials including silencers, antibodies and genetic therapy. Managing CA is a critical challenge for future heart failure care. This review delineates the current standard-of-care and scientific landscape of CA therapy.
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Affiliation(s)
- Julia Vogel
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Alexander Carpinteiro
- Department of Hematology and Stem Cell Transplantation, West German Cancer Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Peter Luedike
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Florian Buehning
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Simon Wernhart
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Tienush Rassaf
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany
| | - Lars Michel
- Department of Cardiology and Vascular Medicine, West German Heart and Vascular Center, University Hospital Essen, Hufelandstraße 55, 45147, Essen, Germany.
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8
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Dobner S, Bernhard B, Ninck L, Wieser M, Bakula A, Wahl A, Köchli V, Spano G, Boscolo Berto M, Elchinova E, Safarkhanlo Y, Stortecky S, Schütze J, Shiri I, Hunziker L, Gräni C. Impact of tafamidis on myocardial function and CMR tissue characteristics in transthyretin amyloid cardiomyopathy. ESC Heart Fail 2024. [PMID: 38736040 DOI: 10.1002/ehf2.14815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 02/28/2024] [Accepted: 04/01/2024] [Indexed: 05/14/2024] Open
Abstract
AIMS Tafamidis improves clinical outcomes in transthyretin amyloid cardiomyopathy (ATTR-CM), yet how tafamidis affects cardiac structure and function remains poorly described. This study prospectively analysed the effect of tafamidis on 12-month longitudinal changes in cardiac structure and function by cardiac magnetic resonance (CMR) compared with the natural course of disease in an untreated historic control cohort. METHODS AND RESULTS ATTR-CM patients underwent CMR at tafamidis initiation and at 12 months. Untreated patients with serial CMRs served as reference to compare biventricular function, global longitudinal strain (GLS), LV mass and extracellular volume fraction (ECV). Thirty-six tafamidis-treated (n = 35; 97.1% male) and 15 untreated patients (n = 14; 93.3% male) with a mean age of 78.3 ± 6.5 and 76.9 ± 6.5, respectively, and comparable baseline characteristics were included. Tafamidis was associated with preserving biventricular function (LVEF (%): 50.5 ± 12 to 50.7 ± 11.5, P = 0.87; RVEF (%): 48.2 ± 10.4 to 48.2 ± 9.4, P = 0.99) and LV-GLS (-9.6 ± 3.2 to -9.9 ± 2.4%; P = 0.595) at 12 months, while a significantly reduced RV-function (50.8 ± 7.3 to 44.2 ± 11.6%, P = 0.028; P (change over time between groups) = 0.032) and numerically worsening LVGLS (-10.9 ± 3.3 to -9.1 ± 2.9%, P = 0.097; P (change over time between groups) = 0.048) was observed without treatment. LV mass significantly declined with tafamidis (184.7 ± 47.7 to 176.5 ± 44.3 g; P = 0.011), yet remained unchanged in untreated patients (163.8 ± 47.5 to 171.2 ± 39.7 g P = 0.356, P (change over time between groups) = 0.027). Irrespective of tafamidis, ECV and native T1-mapping did not change significantly from baseline to 12-month follow-up (P > 0.05). CONCLUSIONS Compared with untreated ATTR-CM patients, initiation of tafamidis preserved CMR-measured biventricular function and reduced LV mass at 12 months. ECV and native T1-mapping did not change significantly comparable to baseline in both groups.
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Affiliation(s)
- Stephan Dobner
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Benedikt Bernhard
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lorenz Ninck
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Monika Wieser
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Adam Bakula
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Andreas Wahl
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Valentin Köchli
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Giancarlo Spano
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Martina Boscolo Berto
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Elena Elchinova
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Yasaman Safarkhanlo
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Stefan Stortecky
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jonathan Schütze
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Isaac Shiri
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lukas Hunziker
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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9
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Porcari A, Sinagra G, Gillmore JD, Fontana M, Hawkins PN. Breakthrough advances enhancing care in ATTR amyloid cardiomyopathy. Eur J Intern Med 2024; 123:29-36. [PMID: 38184468 DOI: 10.1016/j.ejim.2024.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 01/02/2024] [Indexed: 01/08/2024]
Abstract
Transthyretin amyloid cardiomyopathy (ATTR-CM) has been traditionally considered a rare and inexorably fatal condition. ATTR-CM now is an increasingly recognized cause of heart failure (HF) and mortality worldwide with effective pharmacological treatments. Advances in non-invasive diagnosis, coupled with the development of effective treatments, have transformed the diagnosis of ATTR-CM, which is now possible without recourse to endomyocardial biopsy in ≈70 % of cases. Many patients are now diagnosed at an earlier stage. Echocardiography and cardiac magnetic resonance have enabled identification of patients with possible ATTR-CM and more accurate prognostic stratification. Although radionuclide scintigraphy with 'bone' tracers has an established diagnostic value, the diagnostic performance of the bone tracers validated for non-invasive confirmation of ATTR-CM may not be equal. Characterising the wider clinical phenotype of patients with ATTR-CM has enabled identification of features with potential for earlier diagnosis such as carpal tunnel syndrome. Therapies able to slow or halt ATTR-CM progression and increase survival are now available and there is also evidence that patients may benefit from specific conventional HF medications. Cutting-edge research in the field of antibody-mediated removal of ATTR deposits compellingly suggest that ATTR-CM is a truly reversible disorder, bringing hope for patients even with advanced disease. A wide horizon of possibilities is unfolding and awaits discovery.
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Affiliation(s)
- Aldostefano Porcari
- National Amyloidosis Centre, Division of Medicine, Royal Free Campus, University College London, Rowland Hill Street, London NW3 2PF, UK; Centre for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste 34149, Italy; European Reference Network for rare, low prevalence and complex diseases of the heart (ERN GUARD-Heart), Italy.
| | - Gianfranco Sinagra
- Centre for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste 34149, Italy; European Reference Network for rare, low prevalence and complex diseases of the heart (ERN GUARD-Heart), Italy
| | - Julian D Gillmore
- National Amyloidosis Centre, Division of Medicine, Royal Free Campus, University College London, Rowland Hill Street, London NW3 2PF, UK
| | - Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, Royal Free Campus, University College London, Rowland Hill Street, London NW3 2PF, UK
| | - Philip N Hawkins
- National Amyloidosis Centre, Division of Medicine, Royal Free Campus, University College London, Rowland Hill Street, London NW3 2PF, UK
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10
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Datar Y, Clerc OF, Cuddy SAM, Kim S, Taylor A, Neri JC, Benz DC, Bianchi G, Yee AJ, Sanchorawala V, Ruberg FL, Landau H, Liao R, Kijewski MF, Jerosch-Herold M, Kwong RY, Di Carli MF, Falk RH, Dorbala S. Quantification of right ventricular amyloid burden with 18F-florbetapir positron emission tomography/computed tomography and its association with right ventricular dysfunction and outcomes in light-chain amyloidosis. Eur Heart J Cardiovasc Imaging 2024; 25:687-697. [PMID: 38193678 PMCID: PMC11057921 DOI: 10.1093/ehjci/jead350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 12/08/2023] [Accepted: 12/10/2023] [Indexed: 01/10/2024] Open
Abstract
AIMS In systemic light-chain (AL) amyloidosis, quantification of right ventricular (RV) amyloid burden has been limited and the pathogenesis of RV dysfunction is poorly understood. Using 18F-florbetapir positron emission tomography/computed tomography (PET/CT), we aimed to quantify RV amyloid; correlate RV amyloid with RV structure and function; determine the independent contributions of RV, left ventricular (LV), and lung amyloid to RV function; and associate RV amyloid with major adverse cardiac events (MACE: death, heart failure hospitalization, cardiac transplantation). METHODS AND RESULTS We prospectively enrolled 106 participants with AL amyloidosis (median age 62 years, 55% males) who underwent 18F-florbetapir PET/CT, magnetic resonance imaging, and echocardiography. 18F-florbetapir PET/CT identified RV amyloid in 63% of those with and 40% of those without cardiac involvement by conventional criteria. RV amyloid burden correlated with RV ejection fraction (EF), RV free wall longitudinal strain (FWLS), RV wall thickness, RV mass index, N-terminal pro-brain natriuretic peptide, troponin T, LV amyloid, and lung amyloid (each P < 0.001). In multivariable analysis, RV amyloid burden, but not LV or lung amyloid burden, predicted RV dysfunction (EF P = 0.014; FWLS P < 0.001). During a median follow-up of 28 months, RV amyloid burden predicted MACE (P < 0.001). CONCLUSION This study shows for the first time that 18F-florbetapir PET/CT identifies early RV amyloid in systemic AL amyloidosis prior to alterations in RV structure and function. Increasing RV amyloid on 18F-florbetapir PET/CT is associated with worse RV structure and function, predicts RV dysfunction, and predicts MACE. These results imply a central role for RV amyloid in the pathogenesis of RV dysfunction.
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Affiliation(s)
- Yesh Datar
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Olivier F Clerc
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
- CV Imaging Program, Cardiovascular Division and Department of Radiology, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Sarah A M Cuddy
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
- CV Imaging Program, Cardiovascular Division and Department of Radiology, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Sirwoo Kim
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Alexandra Taylor
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Jocelyn Canseco Neri
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Dominik C Benz
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
- CV Imaging Program, Cardiovascular Division and Department of Radiology, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Giada Bianchi
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
- Division of Hematology, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Andrew J Yee
- Division of Hematology and Oncology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Vaishali Sanchorawala
- Section of Hematology, Department of Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Frederick L Ruberg
- Amyloidosis Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
- Section of Cardiovascular Medicine, Department of Medicine, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Heather Landau
- Division of Medical Oncology, Memorial Sloan Kettering Medical Center, New York, NY, USA
| | - Ronglih Liao
- Amyloidosis Program, Stanford University, Stanford, CA, USA
| | - Marie Foley Kijewski
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Michael Jerosch-Herold
- CV Imaging Program, Cardiovascular Division and Department of Radiology, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Raymond Y Kwong
- CV Imaging Program, Cardiovascular Division and Department of Radiology, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Marcelo F Di Carli
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
- CV Imaging Program, Cardiovascular Division and Department of Radiology, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Rodney H Falk
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Sharmila Dorbala
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
- CV Imaging Program, Cardiovascular Division and Department of Radiology, Brigham and Women’s Hospital, 75 Francis St, Boston, MA 02115, USA
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11
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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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12
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Casella M, Compagnucci P, Ciliberti G, Falanga U, Barbarossa A, Valeri Y, Cipolletta L, Volpato G, Stronati G, Rizzo S, De Gaspari M, Vagnarelli F, Lofiego C, Perna GP, Giovagnoni A, Natale A, Basso C, Guerra F, Dello Russo A. Characteristics and Clinical Value of Electroanatomic Voltage Mapping in Cardiac Amyloidosis. Can J Cardiol 2024; 40:372-384. [PMID: 37923125 DOI: 10.1016/j.cjca.2023.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 10/12/2023] [Accepted: 10/26/2023] [Indexed: 11/07/2023] Open
Abstract
BACKGROUND Cardiac amyloidoses (CAs) are an increasingly recognised group of infiltrative cardiomyopathies associated with high risk of adverse cardiac events. We sought to characterise the characteristics and clinical value of right ventricular (RV) electroanatomic voltage mapping (EVM) in CA. METHODS Fifteen consecutive patients undergoing endomyocardial biopsy (EMB) for suspected CA (median age 75 years, 1st-3rd quartiles 64-78 years], 67% male) were enrolled in an observational prospective study. Each patient underwent RV high-density EVM using a multipolar catheter and EMB. The primary outcome was death or heart failure hospitalisation at 1-year follow-up. We recorded electrographic features at EMB sampling sites and electroanatomic data in the overall RV, and explored their correlations with histopathologic findings and primary outcomes events. RESULTS A final EMB-proven diagnosis of immunoglobulin light chain or transthyretin CA was formulated in 6 and 9 patients, respectively. Electrogram amplitudes in the bipolar and unipolar configurations averaged 1.55 ± 0.44 mV and 5.14 ± 1.50 mV, respectively, in the overall RV, with lower values in AL CA patients. We found a significant inverse correlation between both bipolar and unipolar electrogram amplitude and amyloid burden according to EMB (P = 0.001 and P = 0.025, respectively). At 1-year follow-up, 7 patients (47%) experienced a primary outcome event; the extent of bipolar dense scar area at RV EVM was an independent predictor of primary outcome events at multivariable analysis (odds ratio 2.40; P = 0.037). CONCLUSIONS In CA, electrogram amplitudes are around the lower limit of normal yet disproportionately low compared with the increased wall thickness. Out data suggest that RV electrogram amplitude may be a quantitative marker of amyloid burden, and that RV EVM may have prognostic value.
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Affiliation(s)
- Michela Casella
- Cardiology and Arrhythmology Clinic, University Hospital "Azienda Ospedaliero-Universitaria delle Marche," Ancona, Italy; Department of Clinical, Special, and Dental Sciences, Marche Polytechnic University, Ancona, Italy
| | - Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, University Hospital "Azienda Ospedaliero-Universitaria delle Marche," Ancona, Italy.
| | - Giuseppe Ciliberti
- Cardiology and Arrhythmology Clinic, University Hospital "Azienda Ospedaliero-Universitaria delle Marche," Ancona, Italy
| | - Umberto Falanga
- Cardiology and Arrhythmology Clinic, University Hospital "Azienda Ospedaliero-Universitaria delle Marche," Ancona, Italy; Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Alessandro Barbarossa
- Cardiology and Arrhythmology Clinic, University Hospital "Azienda Ospedaliero-Universitaria delle Marche," Ancona, Italy
| | - Yari Valeri
- Cardiology and Arrhythmology Clinic, University Hospital "Azienda Ospedaliero-Universitaria delle Marche," Ancona, Italy; Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Laura Cipolletta
- Cardiology and Arrhythmology Clinic, University Hospital "Azienda Ospedaliero-Universitaria delle Marche," Ancona, Italy
| | - Giovanni Volpato
- Cardiology and Arrhythmology Clinic, University Hospital "Azienda Ospedaliero-Universitaria delle Marche," Ancona, Italy; Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Giulia Stronati
- Cardiology and Arrhythmology Clinic, University Hospital "Azienda Ospedaliero-Universitaria delle Marche," Ancona, Italy; Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Stefania Rizzo
- Cardiovascular Pathology Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, Azienda Ospedaliera-University of Padua, Padova, Italy
| | - Monica De Gaspari
- Cardiovascular Pathology Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, Azienda Ospedaliera-University of Padua, Padova, Italy
| | - Fabio Vagnarelli
- Division of Cardiology, University Hospital "Azienda Ospedaliero-Universitaria delle Marche," Ancona, Italy
| | - Carla Lofiego
- Division of Cardiology, University Hospital "Azienda Ospedaliero-Universitaria delle Marche," Ancona, Italy
| | - Gian Piero Perna
- Division of Cardiology, University Hospital "Azienda Ospedaliero-Universitaria delle Marche," Ancona, Italy
| | - Andrea Giovagnoni
- Department of Clinical, Special, and Dental Sciences, Marche Polytechnic University, Ancona, Italy
| | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, Austin, Texas, USA
| | - Cristina Basso
- Cardiovascular Pathology Unit, Department of Cardiac, Thoracic, Vascular Sciences, and Public Health, Azienda Ospedaliera-University of Padua, Padova, Italy
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, University Hospital "Azienda Ospedaliero-Universitaria delle Marche," Ancona, Italy; Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, University Hospital "Azienda Ospedaliero-Universitaria delle Marche," Ancona, Italy; Department of Biomedical Sciences and Public Health, Marche Polytechnic University, Ancona, Italy
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13
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Santiago LE, Alvi AT, Melnychuk V, Mesquita P, Aneja P. Light-Chain (AL) Cardiac Amyloidosis Presenting as Heart Failure With Reduced Ejection Fraction. Cureus 2024; 16:e55271. [PMID: 38558722 PMCID: PMC10981542 DOI: 10.7759/cureus.55271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/29/2024] [Indexed: 04/04/2024] Open
Abstract
Systemic amyloidosis is caused by the extracellular deposition of misfolded proteins in various organs and usually leads to organ dysfunction. The two common subtypes include light-chain amyloidosis and transthyretin amyloidosis. Deposition of these proteins in the heart can lead to infiltrative and restrictive cardiomyopathy, commonly manifesting as heart failure with preserved ejection fraction. However, systolic heart failure with reduced ejection fraction is mainly seen in the advanced stages of the disease. Here, we present the case of a 53-year-old female who presented with new-onset heart failure with reduced ejection fraction with no prior symptoms or diagnosis of amyloidosis and diastolic dysfunction.
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Affiliation(s)
- Luis E Santiago
- Internal Medicine, HCA Florida Northwest Hospital, Margate, USA
- Internal Medicine, HCA Florida Westside Hospital, Plantation, USA
| | - Ali Tariq Alvi
- Internal Medicine, HCA Florida Northwest Hospital, Margate, USA
- Internal Medicine, HCA Florida Westside Hospital, Plantation, USA
| | - Veniamin Melnychuk
- Internal Medicine, HCA Florida Northwest Hospital, Margate, USA
- Internal Medicine, HCA Florida Westside Hospital, Plantation, USA
| | - Philip Mesquita
- Internal Medicine, HCA Florida Northwest Hospital, Margate, USA
- Internal Medicine, HCA Florida Westside Hospital, Plantation, USA
| | - Pallavi Aneja
- Internal Medicine, HCA Florida Northwest Hospital, Margate, USA
- Internal Medicine, HCA Florida Westside Hospital, Plantation, USA
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14
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Rosengren S, Skibsted Clemmensen T, Hvitfeldt Poulsen S, Tolbod L, Harms HJ, Wikström G, Kero T, Thyrsted Ladefoged B, Sörensen J. Outcome prediction by myocardial external efficiency from 11 C-acetate positron emission tomography in cardiac amyloidosis. ESC Heart Fail 2024; 11:44-53. [PMID: 37806676 PMCID: PMC10804164 DOI: 10.1002/ehf2.14545] [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: 03/28/2023] [Revised: 09/02/2023] [Accepted: 09/15/2023] [Indexed: 10/10/2023] Open
Abstract
AIMS This study aimed to study the prognostic value of myocardial oxygen consumption (MVO2 ) and myocardial external efficiency (MEE) from 11 C-acetate positron emission tomography (PET) in cardiac amyloidosis (CA) patients. METHODS AND RESULTS Forty-eight CA patients, both transthyretin (ATTR) and immunoglobulin light chain (AL) amyloidosis, and 20 controls were included. All subjects were examined with 11 C-acetate PET and echocardiography. MVO2 , forward stroke volume (FSV), and left ventricular mass (LVM) were derived from 11 C-acetate PET and used to calculate MEE. CA patients were followed for survival and the prognostic impact of clinical, echocardiographic, and 11 C-acetate PET parameters was analysed. MVO2 and MEE were reduced in CA compared with controls, but without significant difference between deceased and surviving CA patients. The ratio of 11 C-acetate PET-derived FSV and LVM was also reduced in CA and significantly lowered in deceased patients compared with survivors. In univariate analysis, New York Heart Association class, N-terminal pro-brain natriuretic peptide, and the 11 C-acetate PET parameters FSV/LVM and MEE were the strongest prognostic factors. Of the 11 C-acetate PET parameters, FSV/LVM was the strongest survival predictor with hazard ratio of 0.56 per 0.1 mL/g (95% confidence interval 0.39-0.81, P = 0.002) and independently prognostic in a multivariate model. MEE significantly separated deceased from surviving CA patients with the cut-off of 15.7% (P = 0.032). Survival was significantly shorter with FSV/LVM below 0.27 mL/g (P < 0.001), also when separating AL- and ATTR-CA. CONCLUSIONS Reduced MEE was associated with shorter survival in CA patients, but FSV/LVM was the strongest survival predictor and the only independently prognostic 11 C-acetate PET parameter in multivariate analysis.
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Affiliation(s)
- Sara Rosengren
- Department of Medical Sciences, HaematologyUppsala UniversityIng 100, pl 2, Akademiska Hospital751 85UppsalaSweden
| | | | | | - Lars Tolbod
- Department of Nuclear Medicine and PETAarhus University HospitalAarhusDenmark
| | - Hendrik J. Harms
- Department of Nuclear Medicine and PETAarhus University HospitalAarhusDenmark
| | | | - Tanja Kero
- Department of Surgical Sciences, Nuclear Medicine and PETUppsala UniversityUppsalaSweden
| | | | - Jens Sörensen
- Department of Nuclear Medicine and PETAarhus University HospitalAarhusDenmark
- Department of Surgical Sciences, Nuclear Medicine and PETUppsala UniversityUppsalaSweden
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15
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Alwan L, Benz DC, Cuddy SAM, Dobner S, Shiri I, Caobelli F, Bernhard B, Stämpfli SF, Eberli F, Reyes M, Kwong RY, Falk RH, Dorbala S, Gräni C. Current and Evolving Multimodality Cardiac Imaging in Managing Transthyretin Amyloid Cardiomyopathy. JACC Cardiovasc Imaging 2024; 17:195-211. [PMID: 38099914 DOI: 10.1016/j.jcmg.2023.10.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/06/2023] [Accepted: 10/18/2023] [Indexed: 01/29/2024]
Abstract
Amyloid transthyretin (ATTR) amyloidosis is a protein-misfolding disease characterized by fibril accumulation in the extracellular space that can result in local tissue disruption and organ dysfunction. Cardiac involvement drives morbidity and mortality, and the heart is the major organ affected by ATTR amyloidosis. Multimodality cardiac imaging (ie, echocardiography, scintigraphy, and cardiac magnetic resonance) allows accurate diagnosis of ATTR cardiomyopathy (ATTR-CM), and this is of particular importance because ATTR-targeting therapies have become available and probably exert their greatest benefit at earlier disease stages. Apart from establishing the diagnosis, multimodality cardiac imaging may help to better understand pathogenesis, predict prognosis, and monitor treatment response. The aim of this review is to give an update on contemporary and evolving cardiac imaging methods and their role in diagnosing and managing ATTR-CM. Further, an outlook is presented on how artificial intelligence in cardiac imaging may improve future clinical decision making and patient management in the setting of ATTR-CM.
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Affiliation(s)
- Louhai Alwan
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Dominik C Benz
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; CV Imaging Program, Cardiovascular Division, Department of Medicine and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; Cardiac Imaging, Department of Cardiology and Nuclear Medicine, Zurich University Hospital, Zurich, Switzerland
| | - Sarah A M Cuddy
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; CV Imaging Program, Cardiovascular Division, Department of Medicine and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Stephan Dobner
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Isaac Shiri
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Federico Caobelli
- University Clinic of Nuclear Medicine, Inselspital, Bern University Hospital, Switzerland
| | - Benedikt Bernhard
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland; CV Imaging Program, Cardiovascular Division, Department of Medicine and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Simon F Stämpfli
- Department of Cardiology, Heart Centre Lucerne, Luzerner Kantonsspital, Lucerne, Switzerland
| | - Franz Eberli
- Department of Cardiology, Triemli Hospital (Triemlispital), Zurich, Switzerland
| | - Mauricio Reyes
- Insel Data Science Center, Inselspital, Bern University Hospital, Bern, Switzerland; Artificial Intelligence in Medical Imaging, ARTORG Center for Biomedical Research, University of Bern, Bern, Switzerland
| | - Raymond Y Kwong
- CV Imaging Program, Cardiovascular Division, Department of Medicine and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Rodney H Falk
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Sharmila Dorbala
- Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; CV Imaging Program, Cardiovascular Division, Department of Medicine and Radiology, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Christoph Gräni
- Department of Cardiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland.
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16
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Tender-Vieira J, Pinto C, Matias P, Marques P, Almeida JS. A Straining Heart: Transthyretin Amyloidosis as a Cause of Heart Failure. Cureus 2023; 15:e50957. [PMID: 38249187 PMCID: PMC10800150 DOI: 10.7759/cureus.50957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2023] [Indexed: 01/23/2024] Open
Abstract
Cardiac amyloidosis is a disease caused by the deposition of amyloid fibrils in the extracellular space of the heart, most often by immunoglobulin light chains or by transthyretin. It is often underdiagnosed because the signs and symptoms are nonspecific or due to the false perception that the diagnosis always requires an endomyocardial biopsy. Transthyretin amyloidosis is being increasingly recognized as a cause of heart failure, particularly in patients with heart failure with preserved ejection fraction (HFpEF). We present the clinical case of an 86-year-old man whose diagnosis was based on signs and symptoms compatible with cardiac amyloidosis and in which imaging performed a preponderant role. This case reminds clinicians to consider the diagnosis in older patients with HFpEF, left ventricular hypertrophy and rhythm disturbances. It highlights the importance of evaluating global longitudinal strain (GLS) in a standard echocardiographic evaluation.
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Affiliation(s)
| | - Claudemira Pinto
- Internal Medicine, Centro Hospitalar Universitário de São João, Porto, PRT
| | - Paula Matias
- Internal Medicine, Centro Hospitalar Universitário de São João, Porto, PRT
| | - Pedro Marques
- Internal Medicine, Centro Hospitalar Universitário de São João, Porto, PRT
| | - Jorge S Almeida
- Medicine, Faculdade de Medicina da Universidade do Porto, Porto, PRT
- Internal Medicine, Centro Hospitalar Universitário de São João, Porto, PRT
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17
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Almeida ALC, Melo MDTD, Bihan DCDSL, Vieira MLC, Pena JLB, Del Castillo JM, Abensur H, Hortegal RDA, Otto MEB, Piveta RB, Dantas MR, Assef JE, Beck ALDS, Santo THCE, Silva TDO, Salemi VMC, Rocon C, Lima MSM, Barberato SH, Rodrigues AC, Rabschkowisky A, Frota DDCR, Gripp EDA, Barretto RBDM, Silva SME, Cauduro SA, Pinheiro AC, Araujo SPD, Tressino CG, Silva CES, Monaco CG, Paiva MG, Fisher CH, Alves MSL, Grau CRPDC, Santos MVCD, Guimarães ICB, Morhy SS, Leal GN, Soares AM, Cruz CBBV, Guimarães Filho FV, Assunção BMBL, Fernandes RM, Saraiva RM, Tsutsui JM, Soares FLDJ, Falcão SNDRS, Hotta VT, Armstrong ADC, Hygidio DDA, Miglioranza MH, Camarozano AC, Lopes MMU, Cerci RJ, Siqueira MEMD, Torreão JA, Rochitte CE, Felix A. Position Statement on the Use of Myocardial Strain in Cardiology Routines by the Brazilian Society of Cardiology's Department Of Cardiovascular Imaging - 2023. Arq Bras Cardiol 2023; 120:e20230646. [PMID: 38232246 DOI: 10.36660/abc.20230646] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024] Open
Abstract
Central Illustration : Position Statement on the Use of Myocardial Strain in Cardiology Routines by the Brazilian Society of Cardiology's Department Of Cardiovascular Imaging - 2023 Proposal for including strain in the integrated diastolic function assessment algorithm, adapted from Nagueh et al.67 Am: mitral A-wave duration; Ap: reverse pulmonary A-wave duration; DD: diastolic dysfunction; LA: left atrium; LASr: LA strain reserve; LVGLS: left ventricular global longitudinal strain; TI: tricuspid insufficiency. Confirm concentric remodeling with LVGLS. In LVEF, mitral E wave deceleration time < 160 ms and pulmonary S-wave < D-wave are also parameters of increased filling pressure. This algorithm does not apply to patients with atrial fibrillation (AF), mitral annulus calcification, > mild mitral valve disease, left bundle branch block, paced rhythm, prosthetic valves, or severe primary pulmonary hypertension.
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Affiliation(s)
| | | | | | - Marcelo Luiz Campos Vieira
- Instituto do Coração da Faculdade de Medicina da Universidade de São Paulo (Incor/FMUSP), São Paulo, SP - Brasil
| | - José Luiz Barros Pena
- Faculdade Ciências Médicas de Minas Gerais, Belo Horizonte, MG - Brasil
- Hospital Felicio Rocho, Belo Horizonte, MG - Brasil
| | | | - Henry Abensur
- Beneficência Portuguesa de São Paulo, São Paulo, SP - Brasil
| | | | | | | | | | | | | | | | | | - Vera Maria Cury Salemi
- Instituto do Coração da Faculdade de Medicina da Universidade de São Paulo (Incor/FMUSP), São Paulo, SP - Brasil
| | - Camila Rocon
- Hospital do Coração (HCor), São Paulo, SP - Brasil
| | - Márcio Silva Miguel Lima
- Instituto do Coração da Faculdade de Medicina da Universidade de São Paulo (Incor/FMUSP), São Paulo, SP - Brasil
| | | | | | | | | | - Eliza de Almeida Gripp
- Hospital Pró-Cardiaco, Rio de Janeiro, RJ - Brasil
- Hospital Universitário Antônio Pedro da Universidade Federal Fluminense (UFF), Rio de Janeiro, RJ - Brasil
| | | | | | | | | | | | | | | | | | | | | | | | | | - Maria Veronica Camara Dos Santos
- Departamento de Cardiologia Pediátrica (DCC/CP) da Sociedade Brasileira de Cardiologia (SBC), São Paulo, SP - Brasil
- Sociedade Brasileira de Oncologia Pediátrica, São Paulo, SP - Brasil
| | | | | | - Gabriela Nunes Leal
- Instituto da Criança e do Adolescente do Hospital das Clinicas Faculdade de Medicina da Universidade de São Paulo (FMUSP), São Paulo, SP - Brasil
| | | | | | | | | | | | | | | | | | | | - Viviane Tiemi Hotta
- Instituto do Coração da Faculdade de Medicina da Universidade de São Paulo (Incor/FMUSP), São Paulo, SP - Brasil
- Grupo Fleury, São Paulo, SP - Brasil
| | | | - Daniel de Andrade Hygidio
- Hospital Nossa Senhora da Conceição, Tubarão, SC - Brasil
- Universidade do Sul de Santa Catarina (UNISUL), Tubarão, SC - Brasil
| | - Marcelo Haertel Miglioranza
- EcoHaertel - Hospital Mae de Deus, Porto Alegre, RS - Brasil
- Universidade Federal de Ciências da Saúde de Porto Alegre, Porto Alegre, RS - Brasil
| | | | | | | | | | - Jorge Andion Torreão
- Hospital Santa Izabel, Salvador, BA - Brasil
- Santa Casa da Bahia, Salvador, BA - Brasil
| | - Carlos Eduardo Rochitte
- Instituto do Coração da Faculdade de Medicina da Universidade de São Paulo (Incor/FMUSP), São Paulo, SP - Brasil
- Hospital do Coração (HCor), São Paulo, SP - Brasil
| | - Alex Felix
- Diagnósticos da América SA (DASA), São Paulo, SP - Brasil
- Instituto Nacional de Cardiologia (INC), Rio de Janeiro, RJ - Brasil
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18
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Fontana M, Porcari A, Hawkins PN. Standardising Care and Treatment of Transthyretin Amyloid Cardiomyopathy. Glob Heart 2023; 18:63. [PMID: 38028963 PMCID: PMC10668877 DOI: 10.5334/gh.1275] [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: 09/20/2023] [Accepted: 10/20/2023] [Indexed: 12/01/2023] Open
Abstract
Transthyretin cardiac amyloidosis (ATTR-CA) has been traditionally considered a rare and inexorably fatal condition. ATTR-CA now is an increasingly recognised cause of heart failure and mortality worldwide with effective pharmacological treatments. Advances in non-invasive diagnosis, coupled with the development of effective treatments, have transformed the diagnosis of ATTR-CA, which is now possible without recourse to endomyocardial biopsy in around 70% of cases. Many patients are now diagnosed at an earlier stage. Echocardiography and cardiac magnetic resonance have enabled identification of patients with possible ATTR-CA and more accurate prognostic stratification. Therapies able to slow or halt ATTR-CA progression and increase survival are now available and there is also evidence that patients may benefit from specific conventional heart failure medications. A wide horizon of possibilities is unfolding and awaits discovery.
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Affiliation(s)
- Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Aldostefano Porcari
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
- Centre for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste 34149, IT
- European Reference Network for rare, low prevalence and complex diseases of the heart (ERN GUARD-Heart), Europe
| | - Philip N. Hawkins
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
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19
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Ono R, Falcão LM. Supra-Normal Left Ventricular Function. Am J Cardiol 2023; 207:84-92. [PMID: 37734305 DOI: 10.1016/j.amjcard.2023.08.169] [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: 06/05/2023] [Revised: 08/25/2023] [Accepted: 08/25/2023] [Indexed: 09/23/2023]
Abstract
Heart failure (HF) is often categorized by left ventricular (LV) ejection fraction (LVEF). A new category of HF characterized by supra-normal LVEF (>65%), named HF with supra-normal ejection fraction (HFsnEF), has been recently proposed. Some studies reported that patients with supra-normal LVEF might have an increased risk of long-term major adverse cardiovascular events and U-shaped mortality patterns. Currently, the prognosis of HFsnEF is not well established but seems to be associated with an increased risk of long-term major adverse cardiovascular events. It has been reported that HFsnEF is more prevalent in women and is associated with higher prevalence of nonischemic HF, higher blood urea nitrogen plasma levels, lower levels of natriuretic peptides, and to be less likely treated with β blockers. The pathophysiology of HFsnEF would be associated with microvascular dysfunction because of microvascular inflammation or reduced coronary flow reserve, and low stroke volume index with smaller cardiac chamber dimensions and concentric LV geometry. In this study, we systematically reviewed published data on patients with s supra-normal LV function and reported its definition, proposed pathophysiology, phenotypes, diagnostic strategy, and prognosis.
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Affiliation(s)
- Ryohei Ono
- Department of Cardiovascular Medicine, Chiba University Graduate School of Medicine, Chiba, Japan.
| | - Luiz Menezes Falcão
- Department of Clinical Semiology, Academic Medical Center of Lisbon (CAML); Cardiovascular Center University of Lisbon (CCUL@RISE), Faculty of Medicine University of Lisbon, Lisbon, Portugal
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20
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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: 3] [Impact Index Per Article: 3.0] [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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21
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Brito D, Albrecht FC, de Arenaza DP, Bart N, Better N, Carvajal-Juarez I, Conceição I, Damy T, Dorbala S, Fidalgo JC, Garcia-Pavia P, Ge J, Gillmore JD, Grzybowski J, Obici L, Piñero D, Rapezzi C, Ueda M, Pinto FJ. World Heart Federation Consensus on Transthyretin Amyloidosis Cardiomyopathy (ATTR-CM). Glob Heart 2023; 18:59. [PMID: 37901600 PMCID: PMC10607607 DOI: 10.5334/gh.1262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 08/12/2023] [Indexed: 10/31/2023] Open
Abstract
Transthyretin amyloid cardiomyopathy (ATTR-CM) is a progressive and fatal condition that requires early diagnosis, management, and specific treatment. The availability of new disease-modifying therapies has made successful treatment a reality. Transthyretin amyloid cardiomyopathy can be either age-related (wild-type form) or caused by mutations in the TTR gene (genetic, hereditary forms). It is a systemic disease, and while the genetic forms may exhibit a variety of symptoms, a predominant cardiac phenotype is often present. This document aims to provide an overview of ATTR-CM amyloidosis focusing on cardiac involvement, which is the most critical factor for prognosis. It will discuss the available tools for early diagnosis and patient management, given that specific treatments are more effective in the early stages of the disease, and will highlight the importance of a multidisciplinary approach and of specialized amyloidosis centres. To accomplish these goals, the World Heart Federation assembled a panel of 18 expert clinicians specialized in TTR amyloidosis from 13 countries, along with a representative from the Amyloidosis Alliance, a patient advocacy group. This document is based on a review of published literature, expert opinions, registries data, patients' perspectives, treatment options, and ongoing developments, as well as the progress made possible via the existence of centres of excellence. From the patients' perspective, increasing disease awareness is crucial to achieving an early and accurate diagnosis. Patients also seek to receive care at specialized amyloidosis centres and be fully informed about their treatment and prognosis.
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Affiliation(s)
- Dulce Brito
- Department of Cardiology, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL@RISE, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Fabiano Castro Albrecht
- Dante Pazzanese Institute of Cardiology – Cardiac Amyloidosis Center Dante Pazzanese Institute, São Paulo, Brazil
| | | | - Nicole Bart
- St Vincent’s Hospital, Victor Chang Cardiac Research Institute, University of New South Wales, Sydney, Australia
| | - Nathan Better
- Cabrini Health, Malvern, Royal Melbourne Hospital, Parkville, Monash University and University of Melbourne, Victoria, Australia
| | | | - Isabel Conceição
- Department of Neurosciences and Mental Health, CHULN – Hospital de Santa Maria, Portugal
- Centro de Estudos Egas Moniz Faculdade de Medicina da Universidade de Lisboa Portugal, Portugal
| | - Thibaud Damy
- Department of Cardiology, DHU A-TVB, CHU Henri Mondor, AP-HP, INSERM U955 and UPEC, Créteil, France
- Referral Centre for Cardiac Amyloidosis, GRC Amyloid Research Institute, Reseau amylose, Créteil, France. Filière CARDIOGEN
| | - Sharmila Dorbala
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Cardiac Amyloidosis Program, Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- CV imaging program, Cardiovascular Division and Department of Radiology, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Pablo Garcia-Pavia
- Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, CIBERCV, Madrid, Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, Shanghai, China
| | - Julian D. Gillmore
- National Amyloidosis Centre, University College London, Royal Free Campus, United Kingdom
| | - Jacek Grzybowski
- Department of Cardiomyopathy, National Institute of Cardiology, Warsaw, Poland
| | - Laura Obici
- Amyloidosis Research and Treatment Center, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | | | - Claudio Rapezzi
- Cardiovascular Institute, University of Ferrara, Ferrara, Italy
| | - Mitsuharu Ueda
- Department of Neurology, Graduate School of Medical Sciences, Kumamoto University, Japan
| | - Fausto J. Pinto
- Department of Cardiology, Centro Hospitalar Universitário Lisboa Norte, CAML, CCUL@RISE, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
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22
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Clerc OF, Datar Y, Cuddy SA, Bianchi G, Taylor A, Benz DC, Robertson M, Kijewski MF, Jerosch-Herold M, Kwong RY, Ruberg FL, Liao R, Di Carli MF, Falk RH, Dorbala S. Prognostic Value of Left Ventricular 18 F-Florbetapir Uptake in Systemic Light-Chain Amyloidosis. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.13.23295520. [PMID: 37745589 PMCID: PMC10516059 DOI: 10.1101/2023.09.13.23295520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
Background Myocardial immunoglobulin light-chain (AL) amyloid deposits trigger heart failure, cardiomyocyte stretch and myocardial injury, leading to adverse cardiac outcomes. Positron emission tomography/computed tomography (PET/CT) with 18 F-florbetapir, a novel amyloid-targeting radiotracer, can quantify left ventricular (LV) amyloid burden, but its prognostic value is not known. Therefore, we aimed to evaluate the prognostic value of LV amyloid burden quantified by 18 F-florbetapir PET/CT and to identify mechanistic pathways mediating its association with outcomes. Methods Eighty-one participants with newly-diagnosed systemic AL amyloidosis were prospectively enrolled and underwent 18 F-florbetapir PET/CT. LV amyloid burden was quantified using 18 F-florbetapir LV percent injected dose (%ID). Mayo AL stage was determined using troponin T, N-terminal pro-B-type natriuretic peptide (NT-proBNP), and difference between involved and uninvolved free light chain levels. Major adverse cardiac events (MACE) were defined as all-cause death, heart failure hospitalization, or cardiac transplantation within 12 months. Results Among participants (median age 61 years, 57% males), 36% experienced MACE. Incidence of MACE increased across tertiles of LV amyloid burden from 7% to 63% (p<0.001). LV amyloid burden was significantly associated with MACE in univariable analysis (hazard ratio 1.45, 95% confidence interval 1.15-1.82, p=0.002). However, this association became non-significant in multivariable analyses adjusted for Mayo AL stage. Mediation analysis showed that the association between 18 F-florbetapir LV %ID and MACE was primarily mediated by NT-proBNP (p<0.001), a marker of cardiomyocyte stretch and component of Mayo AL stage. Conclusion In this first study to link cardiac 18 F-florbetapir uptake to subsequent outcomes, LV amyloid burden estimated by LV %ID predicted MACE in AL amyloidosis. But this effect was not independent of Mayo AL stage. LV amyloid burden was associated with MACE primarily via NT-pro-BNP, a marker of cardiomyocyte stretch and component of Mayo AL stage. These findings provide novel insights into the mechanism through which myocardial AL amyloid leads to MACE. Clinical Perspective In systemic light-chain (AL) amyloidosis, cardiac involvement is the key determinant of adverse outcomes. Usually, prognosis is based on the Mayo AL stage, determined by troponin T, N-terminal pro-B-type natriuretic peptide (NT-proBNP), and the difference between involved and uninvolved immunoglobulin free light chain levels (dFLC). Cardiac amyloid burden is not considered in this staging. In the present study, we used the amyloid-specific radiotracer 18 F-florbetapir to quantify left ventricular (LV) amyloid burden in 81 participants with newly-diagnosed AL amyloidosis and evaluated its prognostic value on major adverse outcomes (MACE: all-cause death, heart failure hospitalization, or cardiac transplantation within 12 months). We found that higher LV amyloid burden by 18 F-florbetapir positron emission tomography/computed tomography (PET/CT) was strongly associated with MACE. However, this association became non-significant after adjustment for the Mayo AL stage. Mediation analysis offered novel pathophysiological insights, implying that LV amyloid burden leads to MACE predominantly through cardiomyocyte stretch and light chain toxicity (by NT-proBNP), rather than through myocardial injury (by troponin T), also considering the severity of plasma cell dyscrasia (by dFLC). This mediation by NT-proBNP may explain why the association with outcomes was non-significant with adjustment for Mayo AL stage. Together, these results establish quantitative 18 F-florbetapir PET/CT as a valid method to predict adverse outcomes in AL amyloidosis. These results support the use of 18 F-florbetapir PET/CT to measure the effects of novel fibril-depleting therapies, in addition to plasma cell therapy, to improve outcomes in systemic AL amyloidosis.
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23
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Affiliation(s)
- Sarah A M Cuddy
- Cardiac Amyloidosis Program, Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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24
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Boretto P, Patel NH, Patel K, Rana M, Saglietto A, Soni M, Ahmad M, Sin Ying Ho J, De Filippo O, Providencia RA, Hyett Bray JJ, D’Ascenzo F. Prognosis prediction in cardiac amyloidosis by cardiac magnetic resonance imaging: a systematic review with meta-analysis. EUROPEAN HEART JOURNAL OPEN 2023; 3:oead092. [PMID: 37840586 PMCID: PMC10575621 DOI: 10.1093/ehjopen/oead092] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 08/16/2023] [Accepted: 09/19/2023] [Indexed: 10/17/2023]
Abstract
Cardiac involvement is the foremost determinant of the clinical progression of amyloidosis. The diagnostic role of cardiac magnetic resonance (CMR) imaging in cardiac amyloidosis has been established, but the prognostic role of various right and left CMR tissue characterization and functional parameters, including global longitudinal strain (GLS), late gadolinium enhancement (LGE), and parametric mapping, is yet to be delineated. We searched EMBASE, PubMed, and MEDLINE for studies analysing the prognostic use of CMR imaging in patients with light chain amyloidosis or transthyretin amyloidosis cardiac amyloidosis. The primary endpoint was all-cause mortality. A random effects model was used to calculate a pooled odds ratio using inverse-variance weighting. Nineteen studies with 2199 patients [66% males, median age 59.7 years, interquartile range (IQR) 58-67] were included. Median follow-up was 24 months (IQR 20-32), during which 40.8% of patients died. Both tissue characterization left heart parameters such as elevated extracellular volume [hazard ratio (HR) 3.95, 95% confidence interval (CI) 3.01-5.17], extension of left ventricular (LV) LGE (HR 2.69, 95% CI 2.07-3.49) elevated native T1 (HR 2.19, 95% CI 1.12-4.28), and functional parameters such as reduced LV GLS (HR 1.91, 95% CI 1.52-2.41) and reduced LV ejection fraction (EF; HR 1.20, 95% CI 1.17-1.23) were associated with increased all-cause mortality. Unlike the presence of right ventricular (RV) LGE (HR 3.40, 95% CI 0.51-22.54), parameters such as RV GLS (HR 2.08, 95% CI 1.6-2.69), RVEF (HR 1.13, 95% CI 1.05-1.22), and tricuspid annular systolic excursion (TAPSE) (HR 1.11, 95% CI 1.02-1.21) were also associated with mortality. In this large meta-analysis of patients with cardiac amyloidosis, CMR parameters assessing RV and LV function and tissue characterization were associated with an increased risk of mortality.
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Affiliation(s)
- Paolo Boretto
- Department of Cardiovascular and Thoracic, Città della Salute e della
Scienza Hospital, University of Turin, Corso Bramante, 88,
10126 Turin, Italy
| | - Neal Hitesh Patel
- Research Department of Medical Education, UCL Medical School,
74 Huntley St, WC1E 6DE London, UK
| | - Keval Patel
- Research Department of Medical Education, UCL Medical School,
74 Huntley St, WC1E 6DE London, UK
| | - Mannat Rana
- Research Department of Medical Education, UCL Medical School,
74 Huntley St, WC1E 6DE London, UK
| | - Andrea Saglietto
- Department of Cardiovascular and Thoracic, Città della Salute e della
Scienza Hospital, University of Turin, Corso Bramante, 88,
10126 Turin, Italy
| | - Manas Soni
- Research Department of Medical Education, UCL Medical School,
74 Huntley St, WC1E 6DE London, UK
| | - Mahmood Ahmad
- Department of Cardiology, Royal Free Hospital, Royal Free London NHS
Foundation Trust, 10 Pond St, NW3 2PS London,
UK
| | - Jamie Sin Ying Ho
- Department of Cardiology, Royal Free Hospital, Royal Free London NHS
Foundation Trust, 10 Pond St, NW3 2PS London,
UK
| | - Ovidio De Filippo
- Department of Cardiovascular and Thoracic, Città della Salute e della
Scienza Hospital, University of Turin, Corso Bramante, 88,
10126 Turin, Italy
| | - Rui Andre Providencia
- Institute of Health Informatics Research, University College
London, 222 Euston Road, NW1 2DA London, UK
| | - Jonathan James Hyett Bray
- Institute of Health Informatics Research, University College
London, 222 Euston Road, NW1 2DA London, UK
- Institute of Life Sciences-2, Swansea Bay University Health Board and
Swansea University Medical School, Swansea University, 4
Mumbles Rd, Sketty, SA3 5AU Swansea, UK
| | - Fabrizio D’Ascenzo
- Department of Cardiovascular and Thoracic, Città della Salute e della
Scienza Hospital, University of Turin, Corso Bramante, 88,
10126 Turin, Italy
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25
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Moody WE, Turvey-Haigh L, Knight D, Coats CJ, Cooper RM, Schofield R, Robinson S, Harkness A, Oxborough DL, Gillmore JD, Whelan C, Augustine DX, Fontana M, Steeds RP. British Society of Echocardiography guideline for the transthoracic echocardiographic assessment of cardiac amyloidosis. Echo Res Pract 2023; 10:13. [PMID: 37653443 PMCID: PMC10468878 DOI: 10.1186/s44156-023-00028-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 08/07/2023] [Indexed: 09/02/2023] Open
Abstract
These guidelines form an update of the BSE guideline protocol for the assessment of restrictive cardiomyopathy (Knight et al. in Echo Res Prac, 2013). Since the original recommendations were conceived in 2013, there has been an exponential rise in the diagnosis of cardiac amyloidosis fuelled by increased clinician awareness, improvements in cardiovascular imaging as well as the availability of new and effective disease modifying therapies. The initial diagnosis of cardiac amyloidosis can be challenging and is often not clear-cut on the basis of echocardiography, which for most patients presenting with heart failure symptoms remains the first-line imaging test. The role of a specialist echocardiographer will be to raise the suspicion of cardiac amyloidosis when appropriate, but the formal diagnosis of amyloid sub-type invariably requires further downstream testing. This document seeks to provide a focused review of the literature on echocardiography in cardiac amyloidosis highlighting its important role in the diagnosis, prognosis and screening of at risk individuals, before concluding with a suggested minimum data set, for use as an aide memoire when reporting.
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Affiliation(s)
- William E Moody
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Edgbaston, Birmingham, B15 2TH, UK.
- Institute of Cardiovascular Science, College of Medical and Dental Science, University of Birmingham, Birmingham, UK.
| | - Lauren Turvey-Haigh
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Edgbaston, Birmingham, B15 2TH, UK
| | - Daniel Knight
- Division of Medicine, National Amyloidosis Centre, University College London, London, UK
| | | | - Robert M Cooper
- Liverpool Heart and Chest Hospital, Liverpool, UK
- Liverpool John Moores University, Liverpool, UK
| | | | | | - Allan Harkness
- East Suffolk and North Essex NHS Foundation Trust, Essex, UK
| | - David L Oxborough
- Sports and Exercise Sciences, Liverpool John Moores University, Liverpool, UK
| | - Julian D Gillmore
- Division of Medicine, National Amyloidosis Centre, University College London, London, UK
| | - Carol Whelan
- Division of Medicine, National Amyloidosis Centre, University College London, London, UK
| | - Daniel X Augustine
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
- Department For Health, University of Bath, Bath, UK
| | - Marianna Fontana
- Division of Medicine, National Amyloidosis Centre, University College London, London, UK
| | - Richard P Steeds
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Edgbaston, Birmingham, B15 2TH, UK
- Institute of Cardiovascular Science, College of Medical and Dental Science, University of Birmingham, Birmingham, UK
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26
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Barbieri A, Imberti JF, Bartolomei M, Bonini N, Laus V, Torlai Triglia L, Chiusolo S, Stuani M, Mari C, Muto F, Righelli I, Gerra L, Malaguti M, Mei DA, Vitolo M, Boriani G. Quantification of Myocardial Contraction Fraction with Three-Dimensional Automated, Machine-Learning-Based Left-Heart-Chamber Metrics: Diagnostic Utility in Hypertrophic Phenotypes and Normal Ejection Fraction. J Clin Med 2023; 12:5525. [PMID: 37685592 PMCID: PMC10488495 DOI: 10.3390/jcm12175525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 08/09/2023] [Accepted: 08/17/2023] [Indexed: 09/10/2023] Open
Abstract
Aims: The differentiation of left ventricular (LV) hypertrophic phenotypes is challenging in patients with normal ejection fraction (EF). The myocardial contraction fraction (MCF) is a simple dimensionless index useful for specifically identifying cardiac amyloidosis (CA) and hypertrophic cardiomyopathy (HCM) when calculated by cardiac magnetic resonance. The purpose of this study was to evaluate the value of MCF measured by three-dimensional automated, machine-learning-based LV chamber metrics (dynamic heart model [DHM]) for the discrimination of different forms of hypertrophic phenotypes. Methods and Results: We analyzed the DHM LV metrics of patients with CA (n = 10), hypertrophic cardiomyopathy (HCM, n = 36), isolated hypertension (IH, n = 87), and 54 healthy controls. MCF was calculated by dividing LV stroke volume by LV myocardial volume. Compared with controls (median 61.95%, interquartile range 55.43-67.79%), mean values for MCF were significantly reduced in HCM-48.55% (43.46-54.86% p < 0.001)-and CA-40.92% (36.68-46.84% p < 0.002)-but not in IH-59.35% (53.22-64.93% p < 0.7). MCF showed a weak correlation with EF in the overall cohort (R2 = 0.136) and the four study subgroups (healthy adults, R2 = 0.039 IH, R2 = 0.089; HCM, R2 = 0.225; CA, R2 = 0.102). ROC analyses showed that MCF could differentiate between healthy adults and HCM (sensitivity 75.9%, specificity 77.8%, AUC 0.814) and between healthy adults and CA (sensitivity 87.0%, specificity 100%, AUC 0.959). The best cut-off values were 55.3% and 52.8%. Conclusions: The easily derived quantification of MCF by DHM can refine our echocardiographic discrimination capacity in patients with hypertrophic phenotype and normal EF. It should be added to the diagnostic workup of these patients.
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Affiliation(s)
- Andrea Barbieri
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Jacopo F. Imberti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Mario Bartolomei
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Niccolò Bonini
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Vera Laus
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Laura Torlai Triglia
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Simona Chiusolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Marco Stuani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Chiara Mari
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Federico Muto
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Ilaria Righelli
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Luigi Gerra
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Mattia Malaguti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Davide A. Mei
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Marco Vitolo
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, 41124 Modena, Italy
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, Policlinico di Modena, University of Modena and Reggio Emilia, 41124 Modena, Italy
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27
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Zhang W, Ding J, Wang W, Wang D, Pan Y, Xu D. Status and Future Directions of Therapeutics and Prognosis of Cardiac Amyloidosis. Ther Clin Risk Manag 2023; 19:581-597. [PMID: 37457506 PMCID: PMC10348342 DOI: 10.2147/tcrm.s414821] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 06/19/2023] [Indexed: 07/18/2023] Open
Abstract
Accumulation of aberrant proteins in the heart causes cardiac amyloidosis, an uncommon and complicated illness. It can be classified into two main types: light chain (AL) and transthyretin (ATTR). The diagnosis of cardiac amyloidosis is challenging due to its non-specific clinical presentation and lack of definitive diagnostic tests. Diagnostic accuracy has increased with the advent of modern imaging methods, including cardiac magnetic resonance imaging (MRI) and positron emission tomography (PET) scans. Depending on the severity of cardiac amyloidosis, a number of treatments may be attempted and specified according to the subtype of amyloidosis and the presence of complications. However, there are still significant challenges in treating this condition due to its complexity and lack of effective treatments. The prognosis for patients with cardiac amyloidosis is poor. Despite recent advances in diagnosis and treatment, there is still a need for more effective treatments to improve outcomes for patients with this condition. Therefore, we aim to review the current and future therapeutics reported in the literature and among ongoing clinical trials recruiting patients with CA.
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Affiliation(s)
- Wenbing Zhang
- Department of Cardiology, Jilin Province FAW General Hospital, Changchun, 130000, People’s Republic of China
| | - Jian Ding
- Department of Electrodiagnosis, Jilin Province FAW General Hospital, Changchun, 130000, People’s Republic of China
| | - Wenhai Wang
- Department of Cardiology, Jilin Province FAW General Hospital, Changchun, 130000, People’s Republic of China
| | - Duo Wang
- Department of Geriatrics, Jilin Province FAW General Hospital, Changchun, 130000, People’s Republic of China
| | - Yinping Pan
- Department of Pediatrics, Jilin Province FAW General Hospital, Changchun, 130000, People’s Republic of China
| | - Dexin Xu
- Department of Orthopedics, Jilin Province FAW General Hospital, Changchun, 130000, People’s Republic of China
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28
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Rashdan L, Hodovan J, Masri A. Imaging cardiac hypertrophy in hypertrophic cardiomyopathy and its differential diagnosis. Curr Opin Cardiol 2023:00001573-990000000-00084. [PMID: 37421401 DOI: 10.1097/hco.0000000000001070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/10/2023]
Abstract
PURPOSE OF REVIEW The aim of this study was to review imaging of myocardial hypertrophy in hypertrophic cardiomyopathy (HCM) and its phenocopies. The introduction of cardiac myosin inhibitors in HCM has emphasized the need for careful evaluation of the underlying cause of myocardial hypertrophy. RECENT FINDINGS Advances in imaging of myocardial hypertrophy have focused on improving precision, diagnosis, and predicting prognosis. From improved assessment of myocardial mass and function, to assessing myocardial fibrosis without the use of gadolinium, imaging continues to be the primary tool in understanding myocardial hypertrophy and its downstream effects. Advances in differentiating athlete's heart from HCM are noted, and the increasing rate of diagnosis in cardiac amyloidosis using noninvasive approaches is especially highlighted due to the implications on treatment approach. Finally, recent data on Fabry disease are shared as well as differentiating other phenocopies from HCM. SUMMARY Imaging hypertrophy in HCM and ruling out other phenocopies is central to the care of patients with HCM. This space will continue to rapidly evolve, as disease-modifying therapies are under investigation and being advanced to the clinic.
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Affiliation(s)
- Lana Rashdan
- Hypertrophic Cardiomyopathy Center, Knight Cardiovascular Institute, Oregon Health and Science University, Portland, Oregon, USA
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29
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Yang H, Li R, Ma F, Liu Y, He X, Yang Q, Wang DW, Zeng H, Wang H. Echocardiographic phenotype for refined risk stratification and treatment selection in light chain amyloidosis with heart failure. J Cancer Res Clin Oncol 2023:10.1007/s00432-023-04783-2. [PMID: 37084113 DOI: 10.1007/s00432-023-04783-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 04/15/2023] [Indexed: 04/22/2023]
Abstract
AIMS Light chain amyloidosis (AL) patients with heart failure (HF) are usually with revised Mayo (rMayo) stage III/IV disease and have a poor prognosis. We sought to investigate whether and what echocardiographic phenotype provides value for further risk stratification and guiding optimal risk-adapted treatment in this subgroup of AL patients. METHODS AND RESULTS 95 AL patients who presented with HF and were on rMayo stage III/IV were retrospectively included. Of them, 51 patients (53.7%) were with stage III, 44 (46.3%) were with stage IV, and 44 (46.3%) underwent chemotherapy. Laboratory and echocardiographic measurements were acquired before the initiation of chemotherapy. The relevance of different variables with survival was assessed in the entire cohort, chemotherapy, and non-chemotherapy group. By Multivariate Cox regression analysis, right ventricular wall thickness (RVT) [HR 1.145, 95% confidence interval (CI) 1.026-1.279, P = 0.016], relative wall thickness (RWT) (HR 6.709, 95% CI 1.101-40.877, P = 0.039), and left ventricular ejection fraction (LVEF) < 50% (HR 1.939, 95% CI 1.048-3.590, P = 0.035) were found to be independently associated with survival in the entire cohort, RWT (HR 15.488, 95% CI 2.045-117.292, P = 0.008) in the non-chemotherapy group, and RVT (HR 1.331, 95% CI 1.054-1.681, P = 0.016) in the chemotherapy group, respectively. Kaplan-Meier survival analysis revealed that survival was significantly reduced in the presence of RVT ≥ 6.5 mm or LVEF < 50% in the entire cohort, and the significance of RVT ≥ 6.5 mm was irrespective of rMayo stages. In the chemotherapy group, survival was decreased if RVT ≥ 6.5 mm alone or together with RWT ≥ 0.67 were present, particularly in patients on rMayo stage IV. CONCLUSIONS Echocardiographic phenotype provides incremental value beyond rMayo staging for predicting survival and could further guide treatment in advanced AL with HF. Those with high-risk echocardiographic phenotypes as higher RVT and RWT and lower LVEF had a worse prognosis.
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Affiliation(s)
- Hong Yang
- Division of Cardiology and Department of Internal Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, #1095 Jiefang Ave., Wuhan, 430030, People's Republic of China
| | - Rui Li
- Division of Cardiology and Department of Internal Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, #1095 Jiefang Ave., Wuhan, 430030, People's Republic of China
| | - Fei Ma
- Division of Cardiology and Department of Internal Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, #1095 Jiefang Ave., Wuhan, 430030, People's Republic of China
| | - Yujian Liu
- Division of Cardiology and Department of Internal Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, #1095 Jiefang Ave., Wuhan, 430030, People's Republic of China
| | - Xingwei He
- Division of Cardiology and Department of Internal Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, #1095 Jiefang Ave., Wuhan, 430030, People's Republic of China
| | - Qiao Yang
- Division of Cardiology and Department of Internal Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, #1095 Jiefang Ave., Wuhan, 430030, People's Republic of China
| | - Dao Wen Wang
- Division of Cardiology and Department of Internal Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, #1095 Jiefang Ave., Wuhan, 430030, People's Republic of China
| | - Hesong Zeng
- Division of Cardiology and Department of Internal Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, #1095 Jiefang Ave., Wuhan, 430030, People's Republic of China.
| | - Hong Wang
- Division of Cardiology and Department of Internal Medicine, Tongji Hospital, Tongji Medical College of Huazhong University of Science and Technology, #1095 Jiefang Ave., Wuhan, 430030, People's Republic of China.
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Bukhari S, Oliveros E, Parekh H, Farmakis D. Epidemiology, Mechanisms, and Management of Atrial Fibrillation in Cardiac Amyloidosis. Curr Probl Cardiol 2023; 48:101571. [PMID: 36584731 DOI: 10.1016/j.cpcardiol.2022.101571] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 12/23/2022] [Indexed: 12/29/2022]
Abstract
Cardiac amyloidosis (CA) is a restrictive disease that results from intramyocardial amyloid deposition due to immunoglobulin light chain or transthyretin proteins. Up to two-third of CA patients have atrial fibrillation (AF) due to electromechanical, autonomic, and hemodynamic disturbances. AF in CA carries particularly increased risk of thromboembolism, prompting anticoagulation therapy irrespective of CHA2DS2VASc score. However, CA is also associated with enhanced bleeding risk that warrants thorough assessment of bleeding profile before initiation of anticoagulation. Management of AF in CA is challenging because these patients poorly tolerate rate control agents, while cardiomyopathy precludes most antiarrhythmic agents, leaving amiodarone as the preferred antiarrhythmic drug. The effectiveness of direct current cardioversion in restoring sinus rhythm in CA is comparable with that in the general population, although intraprocedural complication rates could be higher. Transesophageal echocardiogram should be performed prior to direct current cardioversion, given high incidence of intracardiac thrombus in these patients. Finally, the data on catheter ablation is limited.
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Benjamin MM, Arora P, Munir MS, Darki A, Liebo M, Yu M, Syed MA, Kinno M. Association of Left Atrial Hemodynamics by Magnetic Resonance Imaging With Long-Term Outcomes in Patients With Cardiac Amyloidosis. J Magn Reson Imaging 2023; 57:1275-1284. [PMID: 35801623 DOI: 10.1002/jmri.28320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 06/10/2022] [Accepted: 06/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Left atrial (LA) function and strain patterns by magnetic resonance imaging (MRI) have been investigated as markers of several cardiovascular pathologies, including cardiac amyloidosis (CA). However, associations with clinical outcomes have not been investigated. PURPOSE To compare LA function and strain by MRI in CA patients to a matched cohort of patients without cardiovascular disease (CVD) and evaluate the association with long-term clinical outcomes in CA patients. STUDY TYPE Retrospective case control. POPULATION A total of 51 patients with CA and 51 age-, gender-, and race-matched controls without CVD who underwent MRI in sinus rhythm. FIELD STRENGTH/SEQUENCE ECG-gated balanced steady-state free precession sequence at 1.5 T. ASSESSMENT All measurements were completed by one investigator (M.M.B.). LA function and strain parameters were measured including LA indexed minimum and maximum volumes, LA reservoir (R), contractile (CT), and conduit (CD) strain. We compared groups after adjusting for age, hypertension, New York Heart Association class, modified staging system (troponin-I, BNP, estimated GFR) and left ventricular ejection fraction (LVEF) for an endpoint of all-cause mortality and a composite endpoint of heart failure hospitalization (HFH) or death. STATISTICAL TESTS Differences between groups were evaluated with t tests for continuous variables or χ2 tests for categorical variables. A multivariable regression model was used to assess the associations of the P values-two-sided tests-<0.05 were considered statistically significant. RESULTS CA patients with median follow up of 4.9 (8.5) months had significantly lower LA strain and higher LA volumes in comparison to the matched cohort. In the multivariable analysis, only LVEF was significantly associated with death while ƐCT (OR 0.6, CI: 0.41-0.89), indexed minimum LA volume (OR 1.06, CI: 1.02-1.13) and indexed maximum LA volume (OR 1.08, CI: 1.01-1.15) were significantly associated with the composite outcome of death or HFH. CONCLUSION In this retrospective study of CA patients, ƐCT and indexed minimum and maximum LA volumes were significantly associated with the composite outcome of death or HFH. EVIDENCE LEVEL 3 TECHNICAL EFFICACY: Stage 3.
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Affiliation(s)
- Mina M Benjamin
- Division of Cardiovascular Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Punit Arora
- Department of Internal Medicine, Loyola University Medical Center, Maywood, Illinois, USA
| | - Muhammad S Munir
- Department of Internal Medicine, Loyola University Medical Center, Maywood, Illinois, USA
| | - Amir Darki
- Division of Cardiovascular Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Max Liebo
- Department of Cardiology, Loyola University Chicago, Stritch School of Medicine, Loyola University Medical Center, Maywood, Illinois, USA
| | - Mingxi Yu
- Department of Cardiology, Loyola University Chicago, Stritch School of Medicine, Loyola University Medical Center, Maywood, Illinois, USA
| | - Mushabbar A Syed
- Division of Cardiovascular Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Menhel Kinno
- Division of Cardiovascular Medicine, Loyola University Medical Center, Maywood, Illinois
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Knight DS, Karia N, Cole AR, Maclean RH, Brown JT, Masi A, Patel RK, Razvi Y, Chacko L, Venneri L, Kotecha T, Martinez-Naharro A, Kellman P, Scott-Russell AM, Schreiber BE, Ong VH, Denton CP, Fontana M, Coghlan JG, Muthurangu V. Distinct cardiovascular phenotypes are associated with prognosis in systemic sclerosis: a cardiovascular magnetic resonance study. Eur Heart J Cardiovasc Imaging 2023; 24:463-471. [PMID: 35775814 PMCID: PMC10029850 DOI: 10.1093/ehjci/jeac120] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 05/16/2022] [Accepted: 06/13/2022] [Indexed: 11/13/2022] Open
Abstract
AIMS Cardiovascular involvement in systemic sclerosis (SSc) is heterogeneous and ill-defined. This study aimed to: (i) discover cardiac phenotypes in SSc by cardiovascular magnetic resonance (CMR); (ii) provide a CMR-based algorithm for phenotypic classification; and (iii) examine for associations between phenotypes and mortality. METHODS AND RESULTS A retrospective, single-centre, observational study of 260 SSc patients who underwent clinically indicated CMR including native myocardial T1 and T2 mapping from 2016 to 2019 was performed. Agglomerative hierarchical clustering using only CMR variables revealed five clusters of SSc patients with shared CMR characteristics: dilated right hearts with right ventricular failure (RVF); biventricular failure dilatation and dysfunction (BVF); and normal function with average cavity (NF-AC), normal function with small cavity (NF-SC), and normal function with large cavity (NF-LC) sizes. Phenotypes did not co-segregate with clinical or antibody classifications. A CMR-based decision tree for phenotype classification was created. Sixty-three (24%) patients died during a median follow-up period of 3.4 years. After adjustment for age and presence of pulmonary hypertension (PH), independent CMR predictors of all-cause mortality were native T1 (P < 0.001) and right ventricular ejection fraction (RVEF) (P = 0.0032). NF-SC and NF-AC groups had more favourable prognoses (P≤0.036) than the other three groups which had no differences in prognoses between them (P > 0.14). Hazard ratios (HR) were statistically significant for RVF (HR = 8.9, P < 0.001), BVF (HR = 5.2, P = 0.006), and NF-LC (HR = 4.9, P = 0.002) groups. The NF-LC group remained significantly predictive of mortality after adjusting for RVEF, native T1, and PH diagnosis (P = 0.0046). CONCLUSION We identified five CMR-defined cardiac SSc phenotypes that did not co-segregate with clinical data and had distinct outcomes, offering opportunities for a more precision-medicine based management approach.
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Affiliation(s)
- Daniel S Knight
- National Pulmonary Hypertension Service, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
- UCL Department of Cardiac MRI, University College London (Royal Free Campus), Rowland Hill Street, London, NW3 2PF, UK
- Department of Cardiology, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
- UCL Institute of Cardiovascular Science, University College London, Gower Street, London, WC1E 6BT, UK
| | - Nina Karia
- National Pulmonary Hypertension Service, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
- UCL Department of Cardiac MRI, University College London (Royal Free Campus), Rowland Hill Street, London, NW3 2PF, UK
- UCL Institute of Cardiovascular Science, University College London, Gower Street, London, WC1E 6BT, UK
| | - Alice R Cole
- Centre for Rheumatology and Connective Tissue Diseases, UCL Medical School (Royal Free Campus), Rowland Hill Street, London, NW3 2PF, UK
| | - Rory H Maclean
- Centre for Rheumatology and Connective Tissue Diseases, UCL Medical School (Royal Free Campus), Rowland Hill Street, London, NW3 2PF, UK
| | - James T Brown
- National Pulmonary Hypertension Service, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
- UCL Department of Cardiac MRI, University College London (Royal Free Campus), Rowland Hill Street, London, NW3 2PF, UK
- UCL Institute of Cardiovascular Science, University College London, Gower Street, London, WC1E 6BT, UK
| | - Ambra Masi
- UCL Department of Cardiac MRI, University College London (Royal Free Campus), Rowland Hill Street, London, NW3 2PF, UK
- Department of Cardiology, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
| | - Rishi K Patel
- UCL Department of Cardiac MRI, University College London (Royal Free Campus), Rowland Hill Street, London, NW3 2PF, UK
- National Amyloidosis Centre, Division of Medicine, University College London, Rowland Hill Street, London, NW3 2PF, UK
| | - Yousuf Razvi
- UCL Department of Cardiac MRI, University College London (Royal Free Campus), Rowland Hill Street, London, NW3 2PF, UK
- National Amyloidosis Centre, Division of Medicine, University College London, Rowland Hill Street, London, NW3 2PF, UK
| | - Liza Chacko
- UCL Department of Cardiac MRI, University College London (Royal Free Campus), Rowland Hill Street, London, NW3 2PF, UK
- National Amyloidosis Centre, Division of Medicine, University College London, Rowland Hill Street, London, NW3 2PF, UK
| | - Lucia Venneri
- UCL Department of Cardiac MRI, University College London (Royal Free Campus), Rowland Hill Street, London, NW3 2PF, UK
| | - Tushar Kotecha
- National Pulmonary Hypertension Service, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
- UCL Department of Cardiac MRI, University College London (Royal Free Campus), Rowland Hill Street, London, NW3 2PF, UK
- Department of Cardiology, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
- UCL Institute of Cardiovascular Science, University College London, Gower Street, London, WC1E 6BT, UK
| | - Ana Martinez-Naharro
- UCL Department of Cardiac MRI, University College London (Royal Free Campus), Rowland Hill Street, London, NW3 2PF, UK
- Department of Cardiology, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
- National Amyloidosis Centre, Division of Medicine, University College London, Rowland Hill Street, London, NW3 2PF, UK
| | - Peter Kellman
- National Heart, Lung, and Blood Institute, National Institute of Health, 31 Center Dr, Bethesda, MD 20892, USA
| | - Ann M Scott-Russell
- Department of Rheumatology, Queen Alexandra Hospital, Cosham, Portsmouth, PO6 3LY, UK
| | - Benjamin E Schreiber
- National Pulmonary Hypertension Service, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
| | - Voon H Ong
- Centre for Rheumatology and Connective Tissue Diseases, UCL Medical School (Royal Free Campus), Rowland Hill Street, London, NW3 2PF, UK
| | - Christopher P Denton
- Centre for Rheumatology and Connective Tissue Diseases, UCL Medical School (Royal Free Campus), Rowland Hill Street, London, NW3 2PF, UK
| | - Marianna Fontana
- UCL Department of Cardiac MRI, University College London (Royal Free Campus), Rowland Hill Street, London, NW3 2PF, UK
- National Amyloidosis Centre, Division of Medicine, University College London, Rowland Hill Street, London, NW3 2PF, UK
| | - J Gerry Coghlan
- National Pulmonary Hypertension Service, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
- Department of Cardiology, Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
| | - Vivek Muthurangu
- UCL Institute of Cardiovascular Science, University College London, Gower Street, London, WC1E 6BT, UK
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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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Jimenez-Zepeda V, Bril V, Lemieux-Blanchard E, Royal V, McCurdy A, Schwartz D, Davis MK. A Comprehensive Multidisciplinary Diagnostic Algorithm for the Early and Efficient Detection of Amyloidosis. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2023; 23:194-202. [PMID: 36653205 DOI: 10.1016/j.clml.2022.12.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 12/16/2022] [Accepted: 12/21/2022] [Indexed: 12/25/2022]
Abstract
Amyloidosis is a rare protein misfolding disease caused by the accumulation of amyloid fibrils in various tissues and organs. There are different subtypes of amyloidosis, with light chain (AL) amyloidosis being the most common. Amyloidosis is notoriously difficult to diagnose because it is clinically heterogeneous, no single test is diagnostic for the disease, and diagnosis typically involves multiple specialists. Here, we propose an integrated, multidisciplinary algorithm for efficiently diagnosing amyloidosis. Drawing on research from several medical disciplines, we have combined clinical decisions and best practices into a comprehensive algorithm to facilitate the early detection of amyloidosis. Currently, many patients are diagnosed more than 6 months after symptom onset, yet early diagnosis is the major predictor of survival. Our algorithm aims to shorten the time to diagnosis with efficient sequencing of tests and minimizing uninformative investigations. We also recommend typing and staging of confirmed amyloidosis to guide treatment. By reducing time to diagnosis, our algorithm could lead to earlier and more targeted treatment, ultimately improving prognosis and survival.
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Affiliation(s)
- Victor Jimenez-Zepeda
- Department of Hematology, University of Calgary and Arnie Charbonneau Cancer Institute, Calgary, Alberta, Canada.
| | - Vera Bril
- Division of Neurology, Department of Medicine, University of Toronto and University Health Network, Toranto, Ontario, Canada
| | - Emilie Lemieux-Blanchard
- Department of Hematology, Service d'hématologie-oncologie du Centre hospitalier de l'Université de Montréal and Centre de recherche du CHUM, Montreal, Quebec, Canada
| | - Virginie Royal
- Department of Pathology, Hôpital Maisonneuve-Rosemont, Université de Montreal, Montreal, Quebec, Canada
| | - Arleigh McCurdy
- Division of Hematology, The Ottawa Hospital and University of Ottawa, Ottawa, Ontario, Canada
| | - Daniel Schwartz
- Faculty of Medicine, Division of Nephrology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Margot K Davis
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
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Geers J, Luchian ML, Motoc A, De Winter J, Roosens B, Bjerke M, Van Eeckhaut A, Wittens MMJ, Demeester S, Forsyth R, de Ravel T, Bissay V, Schots R, Verbrugge FH, Weytjens C, Weets I, Cosyns B, Droogmans S. Prognostic value of left ventricular global constructive work in patients with cardiac amyloidosis. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2023; 39:585-593. [PMID: 36471103 DOI: 10.1007/s10554-022-02762-1] [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: 11/19/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE The aim of the present study was to evaluate the role of ejection fraction (EF), left ventricular (LV) global longitudinal strain (LVGLS) and global constructive work (GCW) as prognostic variables in patients with cardiac amyloidosis (CA). METHODS CA patients were retrospectively identified between 2015 and 2021 at a tertiary care hospital. Comprehensive clinical, biochemical, and imaging evaluation including two-dimensional (2D) echocardiography with myocardial work (MW) analysis was performed. A clinical combined endpoint was defined as all-cause mortality and heart failure readmission. RESULTS 70 patients were followed for 16 (7-37) months and 37 (52.9%) reached the combined endpoint. Patient with versus without clinical events had a significantly lower LVEF (40.71% vs. 48.01%, p = 0.039), LVGLS (-9.26 vs. -11.32, p = 0.034) and GCW (1034.47mmHg% vs. 1424.86mmHg%, p = 0.011). Multivariable analysis showed that LVEF ( odds ratio (OR): 0.904; 95% confidence interval (CI): 0.839-0.973, p = 0.007), LVGLS ( OR: 0.620; 95% CI: 0.415-0.926, p = 0.020) and GCW ( OR: 0.995; 95% CI: 0.990-0.999, p = 0.016) were significant predictors of outcome, but the model including GCW had the best discriminative ability to predict the combined endpoint (C-index = 0.888). A GCW less than 1443mmHg% was able to predict the clinical endpoint with a sensitivity of 94% and a specificity of 64% (Area under the curve (AUC): 0.771 (95% CI: 0.581-0.961; p = 0.005)). CONCLUSION In CA patients, GCW may be of additional prognostic value to LVEF and GLS in predicting heart failure hospitalization and all-cause mortality.
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Affiliation(s)
- Jolien Geers
- Centrum voor Hart- en Vaatziekten (CHVZ), Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium.
| | - Maria-Luiza Luchian
- Centrum voor Hart- en Vaatziekten (CHVZ), Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Andreea Motoc
- Centrum voor Hart- en Vaatziekten (CHVZ), Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Jari De Winter
- Centrum voor Hart- en Vaatziekten (CHVZ), Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Bram Roosens
- Centrum voor Hart- en Vaatziekten (CHVZ), Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Maria Bjerke
- Department of Clinical Biology, Laboratory of Clinical Neurochemistry, Center for Neurosciences, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Ann Van Eeckhaut
- Department of Clinical Biology, Research Group Experimental Pharmacology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Mandy M J Wittens
- Department of Clinical Biology, Laboratory of Clinical Neurochemistry, Center for Neurosciences, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Simke Demeester
- Department of Clinical Biology, Laboratory of Hematology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Ramses Forsyth
- Department of Pathology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Thomy de Ravel
- Department of Human Genetics, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Véronique Bissay
- Department of Neurology, Center for Neurosciences, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Rik Schots
- Department of Hematology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Frederik H Verbrugge
- Centrum voor Hart- en Vaatziekten (CHVZ), Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Caroline Weytjens
- Centrum voor Hart- en Vaatziekten (CHVZ), Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Ilse Weets
- Department of Clinical Biology, Research Group Experimental Pharmacology, Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Bernard Cosyns
- Centrum voor Hart- en Vaatziekten (CHVZ), Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
| | - Steven Droogmans
- Centrum voor Hart- en Vaatziekten (CHVZ), Universitair Ziekenhuis Brussel (UZ Brussel), Vrije Universiteit Brussel (VUB), Brussels, Belgium
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Matteo S, Anna C, Federico S, Daniele M, Gioele F, Beatrice DP, Rita P, Elisabetta T, Giulia P, Claudio R, Gianluca C. Stroke volume and myocardial contraction fraction in transthyretin amyloidosis cardiomyopathy: A systematic review. Front Cardiovasc Med 2023; 10:1085824. [PMID: 36776259 PMCID: PMC9911429 DOI: 10.3389/fcvm.2023.1085824] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Accepted: 01/06/2023] [Indexed: 01/28/2023] Open
Abstract
Background Cardiac amyloidosis (CA) is primarily a restrictive cardiomyopathy in which the impairment of diastolic function is dominant. Despite this, the left ventricular ejection fraction (LVEF) may be depressed in the late stage of the disease, but it poorly predicts prognosis in the earlier phases and does not represent well the pathophysiology of CA. Many echocardiographic parameters resulted important diagnostic and prognostic tools in patients with CA. Stroke volume (SV) and myocardial contraction fraction (MCF) may be obtained both with echocardiography and cardiac magnetic resonance (MRI). They reflect many factors intrinsically related to the pathophysiology of CA and are therefore potentially associated with symptoms and prognosis in CA. Objectives To collect and summarize the current evidence on SV and MCF and their clinical and prognostic role in transthyretin (TTR-CA). Methods and results We performed a systematic review following the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines. We searched the literature database for studies focusing on SV and MCF in patients with TTR-CA. We analysed the following databases: PUBMED, Cochrane Library, EMBASE, and Web of Science database. Fourteen studies were included in the review. Both SV and MCF have important prognostic implications and are related to mortality. Furthermore, SV is more related to symptoms than LVEF and predicts tolerability of beta-blocker therapy in TTR-CA. Finally, SV showed to be an excellent measure to suggest the presence of TTR-CA in patients with severe aortic stenosis. Conclusion Stroke volume and MCF are very informative parameters that should be routinely assessed during the standard echocardiographic examination of all patients with TTR-CA. They carry a prognostic role while being associated with patients' symptoms. Systematic review registration https://doi.org/10.17605/OSF.IO/ME7DS.
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Quarta CC, Fontana M, Damy T, Catini J, Simoneau D, Mercuri M, Garcia-Pavia P, Maurer MS, Palladini G. Changing paradigm in the treatment of amyloidosis: From disease-modifying drugs to anti-fibril therapy. Front Cardiovasc Med 2022; 9:1073503. [PMID: 36606280 PMCID: PMC9808970 DOI: 10.3389/fcvm.2022.1073503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Accepted: 11/24/2022] [Indexed: 12/24/2022] Open
Abstract
Cardiac amyloidosis is a rare, debilitating, and usually fatal disease increasingly recognized in clinical practice despite patients presenting with non-specific symptoms of cardiomyopathy. The current standard of care (SoC) focuses on preventing further amyloid formation and deposition, either with anti-plasma cell dyscrasia (anti-PCD) therapies in light-chain (AL) amyloidosis or stabilizers of transthyretin (TTR) in transthyretin amyloidosis (ATTR). The SoC is supplemented by therapies to treat the complications arising from organ dysfunction; for example, heart failure, arrhythmia, and proteinuria. Advancements in treatments have improved patient survival, especially for those whose disease is detected and for whom treatment is initiated at an early stage. However, there still are many unmet medical needs, particularly for patients with severe disease for whom morbidity and mortality remain high. There currently are no approved treatments to reverse amyloid infiltration and deplete the amyloid fibrils already deposited in organs, which can continue to cause progressive dysfunction. Anti-fibril therapies aimed at removing the deposited fibrils are being investigated for safety and efficacy in improving outcomes for patients with severe disease. However, there is no clinical evidence yet that removing deposited amyloid fibrils will improve organ function, thereby improving quality of life or extending life. Nevertheless, anti-fibril therapies are actively being investigated in clinical trials to evaluate their ability to complement and synergize with current SoC.
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Affiliation(s)
| | | | - Thibaud Damy
- University Hospital Henri Mondor, Creteil, France
| | - Julia Catini
- Alexion, AstraZeneca Rare Disease, Boston, MA, United States
| | - Damien Simoneau
- Alexion, AstraZeneca Rare Disease, Boston, MA, United States
| | - Michele Mercuri
- Alexion, AstraZeneca Rare Disease, Boston, MA, United States
| | - Pablo Garcia-Pavia
- Hospital Universitario Puerta de Hierro Majadahonda, Instituto de Investigación Sanitaria Puerta de Hierro Segovia de Arana (IDIPHISA), Centro de Investigación Biomédica en Red Enfermedades Cardiovasulares (CIBERCV), Madrid, Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Mathew S. Maurer
- Columbia University Irving Medical Center, New York Presbyterian Hospital, New York, NY, United States
| | - Giovanni Palladini
- Department of Molecular Medicine, University of Pavia, and Amyloidosis Research and Treatment Center, Foundation “Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS) Policlinico San Matteo”, Pavia, Italy
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Patel RK, Ioannou A, Razvi Y, Chacko L, Venneri L, Bandera F, Knight D, Kotecha T, Martinez‐Naharro A, Masi A, Porcari A, Brown J, Patel K, Manisty C, Moon J, Rowczenio D, Gilbertson JA, Sinagra G, Lachmann H, Wechalekar A, Petrie A, Whelan C, Hawkins PN, Gillmore JD, Fontana M. Sex differences among patients with transthyretin amyloid cardiomyopathy - from diagnosis to prognosis. Eur J Heart Fail 2022; 24:2355-2363. [PMID: 36575133 PMCID: PMC10087683 DOI: 10.1002/ejhf.2646] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/29/2022] [Accepted: 07/29/2022] [Indexed: 01/18/2023] Open
Abstract
AIMS Transthyretin amyloid cardiomyopathy (ATTR-CM) is predominantly diagnosed in men. The few available studies suggest affected women have a more favourable cardiac phenotype. We aimed to characterize sex differences among consecutive patients with non-hereditary and two prevalent forms of hereditary (h)ATTR-CM diagnosed over a 20-year period. METHODS AND RESULTS Analysis of deep phenotyping at presentation, changes on serial echocardiography and overall prognosis were evaluated. In total, 1732 consecutive patients were studied, comprising: 1095 with wild-type (wt)ATTR-CM; 206 with T60A-hATTR-CM; and 431 with V122I-hATTR-CM. Female prevalence was greater in T60A-hATTR-CM (29.6%) and V122I-hATTR-CM (27.8%) compared to wtATTR-CM (6%). At presentation, females were 3.3 years older than males (wtATTR-CM: 81.9 vs. 77.8 years; T60A-hATTR-CM: 68.7 vs. 65.1 years; V122I-hATTR-CM: 77.1 vs. 74.9 years). Body size significantly influenced measures of disease severity; when indexed, overall structural and functional phenotype was similar between sexes, the few significant differences suggested a mildly worse phenotype in females. No significant differences were observed in both disease progression on serial echocardiography and mortality across the overall population (p = 0.459) and when divided by genotype (wtATTR-CM: p = 0.730; T60A-hATTR-CM: p = 0.161; V122I-hATTR-CM: p = 0.056). CONCLUSION This study of a well-characterized large cohort of ATTR-CM patients did not demonstrate overall differences between sexes in either clinical phenotype, when indexed, or with respect to disease progression and prognosis. Non-indexed wall thickness measurements may have contributed to both under-representation and delays in diagnosis for affected females and highlights the potential role of utilizing indexed echocardiographic parameters for a more accurate assessment of patients at diagnosis and for disease prognostication.
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Affiliation(s)
- Rishi K. Patel
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Adam Ioannou
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Yousuf Razvi
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Liza Chacko
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Lucia Venneri
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Francesco Bandera
- Heart Failure Unit, Cardiology University DepartmentIRCCS Policlinico San DonatoMilanItaly
- Department for Biomedical Sciences for HealthUniversity of MilanoMilanItaly
| | - Daniel Knight
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Tushar Kotecha
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Ana Martinez‐Naharro
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Ambra Masi
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Aldostefano Porcari
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular DepartmentAzienda Sanitaria Universitaria Giuliano‐Isontina (ASUGI), University of TriesteTriesteItaly
| | - James Brown
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Kiara Patel
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Charlotte Manisty
- Barts Heart Centre, The Cardiovascular Magnetic Resonance Imaging Unit, and the Inherited Cardiovascular Diseases UnitSt Bartholomew's HospitalLondonUK
| | - James Moon
- Barts Heart Centre, The Cardiovascular Magnetic Resonance Imaging Unit, and the Inherited Cardiovascular Diseases UnitSt Bartholomew's HospitalLondonUK
| | - Dorota Rowczenio
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Janet A. Gilbertson
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Gianfranco Sinagra
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular DepartmentAzienda Sanitaria Universitaria Giuliano‐Isontina (ASUGI), University of TriesteTriesteItaly
| | - Helen Lachmann
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Ashutosh Wechalekar
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Aviva Petrie
- Eastman Dental Institute, University College LondonLondonUK
| | - Carol Whelan
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Philip N. Hawkins
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Julian D. Gillmore
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
| | - Marianna Fontana
- National Amyloidosis Centre, Division of MedicineUniversity College LondonLondonUK
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Wang X, Guo Y, Gao Y, Ren C, Huang Z, Liu B, Li X, Chang L, Shen K, Ding H, Zhang H, Tian Z, Hacker M, Zhang S, Wang Y, Li J, Li X, Huo L. Feasibility of 68Ga-Labeled Fibroblast Activation Protein Inhibitor PET/CT in Light-Chain Cardiac Amyloidosis. JACC Cardiovasc Imaging 2022; 15:1960-1970. [PMID: 36357138 DOI: 10.1016/j.jcmg.2022.06.004] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 05/23/2022] [Accepted: 06/16/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Systemic amyloid light chain (AL) amyloidosis is the most common type of amyloidosis, leading to cardiomyocyte necrosis and interstitial fibrosis. Gallium-68-labeled fibroblast activation protein inhibitor 04 (68Ga-FAPI-04) has recently been introduced for imaging fibroblast activation in cardiac diseases. To date, cardiac fibroblast and cardiac amyloidosis (CA) phenotype activities have not been mapped. OBJECTIVES The aim of this study was to evaluate the feasibility of 68Ga-FAPI-04 positron emission tomography (PET)/computed tomography (CT) in assessing AL CA. METHODS Thirty consecutive patients (mean age: 59.1 ± 7.7 years; 20 men, 10 women) with biopsy-proven AL amyloidosis were enrolled prospectively (including 27 with AL CA and 3 without AL CA). All patients underwent 68Ga-FAPI-04 PET/CT (107.4 ± 26.5 MBq). Global standardized uptake values and left ventricular (LV) molecular volume were calculated in correlation to echocardiography (n = 30), cardiac magnetic resonance (n = 18), and clinical biomarkers. Subsequently, the patients were categorized as having patchy (PET-patchy), extensive (PET-extensive), and negative (PET-negative) patterns. RESULTS Of all patients, 80% (24 of 30) showed increased LV uptake (PET-patchy [n = 4] vs PET-extensive [n = 20]), whereas 6 patients did not show visible myocardial uptake. Standardized uptake value ratio and LV molecular volume were significantly higher in the PET-extensive than the PET-patchy group (2.79 mL ± 1.22 mL vs 1.53 mL ± 0.66 mL [P = 0.045] and 198.3 mL ± 59.97 mL vs 127.8 mL ± 25.82 [P = 0.005], respectively). Additionally, 68Ga-FAPI-04 uptake was significantly correlated with clinical biomarkers (Mayo stage and N-terminal pro-brain natriuretic peptide), interventricular septal thickness, left ventricular ejection fraction (LVEF), LV end-systolic volume, extracellular volume, and LV global strain (P < 0.05). CONCLUSIONS 68Ga-FAPI-04 PET/CT is feasible in detecting myocardial fibroblast activation in patients with AL CA in correlation with myocardial remodeling. It might provide complementary information on cardiac molecular characterization and staging of disease.
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Affiliation(s)
- Xuezhu Wang
- Department of Nuclear Medicine, Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Center for Rare Diseases Research, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yubo Guo
- Department of Radiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yajuan Gao
- Department of Hematology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Chao Ren
- Department of Nuclear Medicine, Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Center for Rare Diseases Research, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | | | - Bowei Liu
- Department of Biomedical Engineering, Tsinghua University, Beijing, China
| | - Xiao Li
- Department of Radiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Long Chang
- Department of Hematology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Kaini Shen
- Department of Hematology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Haiyan Ding
- Department of Biomedical Engineering, Tsinghua University, Beijing, China
| | - Hui Zhang
- Department of Biomedical Engineering, Tsinghua University, Beijing, China
| | - Zhuang Tian
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Marcus Hacker
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Shuyang Zhang
- Department of Cardiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yining Wang
- Department of Radiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jian Li
- Department of Hematology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Xiang Li
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria.
| | - Li Huo
- Department of Nuclear Medicine, Beijing Key Laboratory of Molecular Targeted Diagnosis and Therapy in Nuclear Medicine, State Key Laboratory of Complex Severe and Rare Diseases, Center for Rare Diseases Research, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Guo Y, Li X, Wang Y. State of the Art: Quantitative Cardiac MRI in Cardiac Amyloidosis. J Magn Reson Imaging 2022; 56:1287-1301. [PMID: 35770942 DOI: 10.1002/jmri.28314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2022] [Revised: 06/08/2022] [Accepted: 06/08/2022] [Indexed: 12/15/2022] Open
Abstract
Cardiac amyloidosis (CA) is characterized by amyloid infiltration in the myocardial extracellular space, causing heart failure. Patients with CA are currently underdiagnosed. Cardiac involvement is significantly associated with the prognosis and treatment decision-making for CA. Early identification and accurate stratification are the crucial first step in patient management. Comprehensive cardiac MRI-based evaluation of the cardiac structure, function, and myocardial tissue characterization assesses cardiac involvement by tracing disease processes. Emerging quantitative tissue characterization techniques have introduced new measures that can identify early staged CA and monitor disease progression or response after treatment. Quantitative cardiac MRI is becoming an instrumental tool in understanding CA, which leads to changes in individualized patient care. This review aimed to discuss the quantitative cardiac MRI-based assessment of CA using established and emerging techniques. EVIDENCE LEVEL: 5 TECHNICAL EFFICACY: Stage 3.
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Affiliation(s)
- Yubo Guo
- Department of Radiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Xiao Li
- Department of Radiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Yining Wang
- Department of Radiology, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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Beyond Sarcomeric Hypertrophic Cardiomyopathy: How to Diagnose and Manage Phenocopies. Curr Cardiol Rep 2022; 24:1567-1585. [PMID: 36053410 DOI: 10.1007/s11886-022-01778-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/20/2022] [Indexed: 01/11/2023]
Abstract
PURPOSE OF REVIEW We describe the most common phenocopies of hypertrophic cardiomyopathy, their pathogenesis, and clinical presentation highlighting similarities and differences. We also suggest a step-by-step diagnostic work-up that can guide in differential diagnosis and management. RECENT FINDINGS In the last years, a wider application of genetic testing and the advances in cardiac imaging have significantly changed the diagnostic approach to HCM phenocopies. Different prognosis and management, with an increasing availability of disease-specific therapies, make differential diagnosis mandatory. The HCM phenotype can be the cardiac manifestation of different inherited and acquired disorders presenting different etiology, prognosis, and treatment. Differential diagnosis requires a cardiomyopathic mindset allowing to recognize red flags throughout the diagnostic work-up starting from clinical and family history and ending with advanced imaging and genetic testing. Different prognosis and management, with an increasing availability of disease-specific therapies make differential diagnosis mandatory.
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Cuddy SA, Datar Y, Ovsak G, Saith S, Murphy SP, Bay CP, Haddad M, Lilleness B, Muralidhar V, Pipilas A, Vuong J, Guardino E, Maurer MS, Ruberg FL, Falk RH, Dorbala S. Optimal Echocardiographic Parameters to Improve the Diagnostic Yield of Tc-99m-Bone Avid Tracer Cardiac Scintigraphy for Transthyretin Cardiac Amyloidosis. Circ Cardiovasc Imaging 2022; 15:e014645. [PMID: 36378779 PMCID: PMC9667717 DOI: 10.1161/circimaging.122.014645] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 09/30/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Echocardiographic deformation-based ratios and novel multi-parametric scores have been suggested to discriminate transthyretin cardiac amyloidosis (ATTR-CM) from other causes of increased left ventricular wall thickness among patients referred for ATTR-CM evaluation. Their relative predictive accuracy has not been well studied. We sought to (1) identify echocardiographic parameters predictive of ATTR-CM and (2) compare the diagnostic accuracy of these parameters in patients with suspected ATTR-CM referred for technetium-99m-pyrophosphate scintigraphy. METHODS Echocardiograms from 598 patients referred to 3 major amyloidosis centers for technetium-99m-pyrophosphate to detect ATTR-CM were analyzed, including longitudinal strain (LS) analysis. Deformation ratios (septal apex to base ratio, relative apical sparing, ejection fraction to global LS), a multi-center European increased wall thickness score, and Mayo Clinic derived ATTR score (transthyretin cardiac amyloidosis score) were calculated. A logistic regression model was used to identify the parameters that best associated with a diagnosis of ATTR-CM. Comparison of the diagnostic capacity of the parameters was performed by receiver operating characteristic curves and the area under the curve (AUC). RESULTS Over half of the subjects (54.2%) were diagnosed with ATTR-CM (78% were men, median age of 76 years). Age, inferolateral wall thickness, and basal LS were the strongest predictors of ATTR-CM, AUC of 0.87 (95% CI: 0.83, 0.90), superior to the increased wall thickness score AUC of 0.78 (95% CI: 0.73, 0.83; P=0.004). An inferolateral wall thickness of ≥14 mm (AUC: 0.73) was as accurate as the published cut-offs for transthyretin cardiac amyloidosis score and septal apex to base (AUC: 0.72 and 0.69, P=0.8 and P=0.1, respectively), and was superior to ejection fraction to global LS and relative apical sparing (AUC: 0.64 and 0.53, P<0.001, respectively). A cut-off of ≥-8% for average basal LS (AUC: 0.76, CI: 0.72-0.79) had a similar area under the curve to transthyretin cardiac amyloidosis score (TCAS) (P=0.2); outperforming the other indices (P<0.01). CONCLUSION Inferolateral wall thickness and average basal LS performed as well as or better than more complex echo ratios and multiparametric scores to predict ATTR-CM.
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Affiliation(s)
- Sarah Am Cuddy
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA (S.A.M.C., Y.D., S.P.M., M.H., R.H.F., S.D.)
- CV imaging program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, MA (S.A.M.C., Y.D., G.O., S.D.)
| | - Yesh Datar
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA (S.A.M.C., Y.D., S.P.M., M.H., R.H.F., S.D.)
- CV imaging program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, MA (S.A.M.C., Y.D., G.O., S.D.)
| | - Gavin Ovsak
- CV imaging program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, MA (S.A.M.C., Y.D., G.O., S.D.)
| | - Sunil Saith
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY (S.S., M.S.M.)
| | - Sean P Murphy
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA (S.A.M.C., Y.D., S.P.M., M.H., R.H.F., S.D.)
| | - Camden P Bay
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, MA (C.P.B., S.D.)
| | - Mia Haddad
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA (S.A.M.C., Y.D., S.P.M., M.H., R.H.F., S.D.)
| | - Brian Lilleness
- Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine/Boston Medical Center, Boston, MA (B.L., V.M., A.P., J.V., E.G., F.L.R.)
| | - Varsha Muralidhar
- Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine/Boston Medical Center, Boston, MA (B.L., V.M., A.P., J.V., E.G., F.L.R.)
| | - Alexandra Pipilas
- Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine/Boston Medical Center, Boston, MA (B.L., V.M., A.P., J.V., E.G., F.L.R.)
| | - Jacqueline Vuong
- Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine/Boston Medical Center, Boston, MA (B.L., V.M., A.P., J.V., E.G., F.L.R.)
| | - Eric Guardino
- Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine/Boston Medical Center, Boston, MA (B.L., V.M., A.P., J.V., E.G., F.L.R.)
| | - Mathew S Maurer
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY (S.S., M.S.M.)
| | - Frederick L Ruberg
- Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine/Boston Medical Center, Boston, MA (B.L., V.M., A.P., J.V., E.G., F.L.R.)
| | - Rodney H Falk
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA (S.A.M.C., Y.D., S.P.M., M.H., R.H.F., S.D.)
| | - Sharmila Dorbala
- Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, MA (S.A.M.C., Y.D., S.P.M., M.H., R.H.F., S.D.)
- CV imaging program, Cardiovascular Division and Department of Radiology, Brigham and Women's Hospital, Boston, MA (S.A.M.C., Y.D., G.O., S.D.)
- Division of Nuclear Medicine, Department of Radiology, Brigham and Women's Hospital, Boston, MA (C.P.B., S.D.)
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Rapezzi C, Aimo A, Barison A, Emdin M, Porcari A, Linhart A, Keren A, Merlo M, Sinagra G. Restrictive cardiomyopathy: definition and diagnosis. Eur Heart J 2022; 43:4679-4693. [PMID: 36269634 PMCID: PMC9712030 DOI: 10.1093/eurheartj/ehac543] [Citation(s) in RCA: 48] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/23/2022] [Accepted: 09/16/2022] [Indexed: 01/05/2023] Open
Abstract
Restrictive cardiomyopathy (RCM) is a heterogeneous group of diseases characterized by restrictive left ventricular pathophysiology, i.e. a rapid rise in ventricular pressure with only small increases in filling volume due to increased myocardial stiffness. More precisely, the defining feature of RCM is the coexistence of persistent restrictive pathophysiology, diastolic dysfunction, non-dilated ventricles, and atrial dilatation, regardless of ventricular wall thickness and systolic function. Beyond this shared haemodynamic hallmark, the phenotypic spectrum of RCM is wide. The disorders manifesting as RCM may be classified according to four main disease mechanisms: (i) interstitial fibrosis and intrinsic myocardial dysfunction, (ii) infiltration of extracellular spaces, (iii) accumulation of storage material within cardiomyocytes, or (iv) endomyocardial fibrosis. Many disorders do not show restrictive pathophysiology throughout their natural history, but only at an initial stage (with an evolution towards a hypokinetic and dilated phenotype) or at a terminal stage (often progressing from a hypertrophic phenotype). Furthermore, elements of both hypertrophic and restrictive phenotypes may coexist in some patients, making the classification challenge. Restrictive pathophysiology can be demonstrated by cardiac catheterization or Doppler echocardiography. The specific conditions may usually be diagnosed based on clinical data, 12-lead electrocardiogram, echocardiography, nuclear medicine, or cardiovascular magnetic resonance, but further investigations may be needed, up to endomyocardial biopsy and genetic evaluation. The spectrum of therapies is also wide and heterogeneous, but disease-modifying treatments are available only for cardiac amyloidosis and, partially, for iron overload cardiomyopathy.
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Affiliation(s)
- Claudio Rapezzi
- Corresponding author. Tel: +39 0532239882, Fax: +39 0532 293031,
| | - Alberto Aimo
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, piazza Martiri della Libertà 33, 56127 Pisa, Italy,Cardiology Division, Fondazione Toscana Gabriele Monasterio, via Moruzzi 1, 56124 Pisa, Italy
| | - Andrea Barison
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, piazza Martiri della Libertà 33, 56127 Pisa, Italy,Cardiology Division, Fondazione Toscana Gabriele Monasterio, via Moruzzi 1, 56124 Pisa, Italy
| | - Michele Emdin
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, piazza Martiri della Libertà 33, 56127 Pisa, Italy,Cardiology Division, Fondazione Toscana Gabriele Monasterio, via Moruzzi 1, 56124 Pisa, Italy
| | - Aldostefano Porcari
- Center 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, Via Giacomo Puccini, 50, 34148 Trieste, Italy
| | - Ales Linhart
- General University Hospital and Charles University, Opletalova 38, 110 00 Staré Město, Czech Republic
| | - Andre Keren
- Cardiology Division, Hadassah Hebrew University Hospital, Sderot Churchill 8, Jerusalem, Israel,Heart Failure Center, Clalit Health Services, Bnei Brit St 22, Jerusalem, Israel
| | - Marco Merlo
- Center 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, Via Giacomo Puccini, 50, 34148 Trieste, Italy
| | - Gianfranco Sinagra
- Center 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, Via Giacomo Puccini, 50, 34148 Trieste, Italy
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44
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Di Bella G, Cappelli F, Licordari R, Piaggi P, Campisi M, Bellavia D, Minutoli F, Gentile L, Russo M, de Gregorio C, Perfetto F, Mazzeo A, Falletta C, Clemenza F, Vita G, Carerj S, Aquaro GD. Prevalence and diagnostic value of extra-left ventricle echocardiographic findings in transthyretin-related cardiac amyloidosis. Amyloid 2022; 29:197-204. [PMID: 35465808 DOI: 10.1080/13506129.2022.2064739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
BACKGROUND Cardiac amyloidosis (CA) is cardiomyopathy with a hypertrophic phenotype characterised by diffuse deposition of anomalous fibrillar proteins in the extracellular matrix. OBJECTIVES To evaluate the prevalence and diagnostic value of extra left ventricle echocardiographic findings in patients with left ventricular (LV) hypertrophic phenotype and amyloid deposition. METHODS A group of 146 patients with LV thickness ≥15 mm were enrolled: 70 patients who received a definite diagnosis of sarcomeric hypertrophic cardiomyopathy (HCM group) and 76 patients with transthyretin cardiac amyloidosis (CA group). Echocardiographic analysis of crista terminalis (CriT), atrio-ventricular plane (AVP), mitro-aortic lamina (MAL), anterior ascending aortic wall, interatrial septum (IAS), Eustachian valve (EusV) and coumadin ridge (CouR) was performed in all patients, and these structures were compared among the two groups. RESULTS CA group showed significantly higher dimensions of CriT, IAS, CouR, AVP, MAL and IAS compared to the HCM group. The logistic analysis showed that LV EF, LV septal thickness, CriT presence, CriT area, MAL and IAS were all predictors of CA in univariate analyses. The stepwise multivariate analysis showed independent predictors of CA: CriT area, MAL and LVEF. According to areas under the receiver operating characteristic curves the best cut-off values to determine CA were identified (IAS > 9 mm, MAL > 7 mm, CriT > 9 mm2). Among these 3 independent predictors, IAS > 9 mm had the best specificity (96%) and positive predictive value (93%) in identifying CA. CONCLUSIONS evidence of extra left ventricle sites of amyloid deposition is a frequent finding in CA. In the context of hypertrophic phenocopies, an increased thickness of IAS, and/or CT and/or MAL should suggest a diagnosis of transthyretin CA.
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Affiliation(s)
- Gianluca Di Bella
- Rare Cardiac Disease Centre, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Francesco Cappelli
- Tuscan Regional Amyloid Center, Careggi University Hospital, Firenze, Italy
| | - Roberto Licordari
- Rare Cardiac Disease Centre, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Paolo Piaggi
- Department of Clinical and Experimental Medicine, Section of Endocrinology, University of Pisa, Pisa, Italy
| | - Mariapaola Campisi
- Rare Cardiac Disease Centre, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Diego Bellavia
- Division of Cardiovascular Diseases, Cardio-Thoracic Department, IRCCS-ISMETT, Palermo, Italy
| | - Fabio Minutoli
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Luca Gentile
- Rare Cardiac Disease Centre, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Massimo Russo
- Rare Cardiac Disease Centre, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Cesare de Gregorio
- Rare Cardiac Disease Centre, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Federico Perfetto
- Tuscan Regional Amyloid Center, Careggi University Hospital, Firenze, Italy
| | - Anna Mazzeo
- Rare Cardiac Disease Centre, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Calogero Falletta
- Division of Cardiovascular Diseases, Cardio-Thoracic Department, IRCCS-ISMETT, Palermo, Italy
| | - Francesco Clemenza
- Division of Cardiovascular Diseases, Cardio-Thoracic Department, IRCCS-ISMETT, Palermo, Italy
| | - Giuseppe Vita
- Rare Cardiac Disease Centre, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Scipione Carerj
- Rare Cardiac Disease Centre, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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45
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Lin YH, Hsueh HW, Su MY, Cheng MF, Chiang MC, Juang JMJ, Kao YH, Chang KC, Feng FP, Hsieh ST, Chao CC. Cardiomyopathy correlates to nerve damage in p.A117S late-onset transthyretin amyloid polyneuropathy. Ann Clin Transl Neurol 2022; 9:1359-1369. [PMID: 35945697 PMCID: PMC9463956 DOI: 10.1002/acn3.51635] [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: 06/08/2022] [Revised: 06/30/2022] [Accepted: 07/07/2022] [Indexed: 11/22/2022] Open
Abstract
Objective Late‐onset hereditary transthyretin amyloidosis with polyneuropathy (ATTRv‐PN) is often associated with heart involvement. Recent advances in cardiac imaging allow the detection of cardiac amyloidosis. This study aimed to explore cardiomyopathy by cardiac imaging and its clinical correlates with polyneuropathy in late‐onset ATTRv‐PN. Methods Polyneuropathy was assessed by intraepidermal nerve fiber (IENF) density, nerve conduction study (NCS), autonomic function tests, quantitative sensory testing, and clinical questionnaires. Cardiomyopathy was evaluated by echocardiography, 99mTc‐pyrophosphate (PYP) single‐photon emission computed tomography (SPECT) imaging, cardiac magnetic resonance imaging (CMR), and serum Pro‐B‐type natriuretic peptide. Healthy controls and patients with Brugada syndrome were enrolled for comparison of CMR. Results Fifty late‐onset ATTRv‐PN patients (38 men, 46 with p. A117S mutation), aged 63.7 ± 5.5 years, of polyneuropathy disability stage 1–4 were enrolled. All patients presented polyneuropathy in NCS, and 74.5% of patients had reduced IENF density in distal legs. All patients showed significant radiotracer uptake in the heart on 99mTc‐PYP SPECT imaging, and 87.8% of patients had abnormally increased left ventricular (LV) septum thickness on echocardiography. CMR showed longer myocardial native T1, larger extracellular volume, greater LV mass index, and higher LV mass to end‐diastolic volume ratio in ATTRv‐PN patients than healthy controls and patients with Brugada syndrome. These CMR parameters were associated with skin denervation, absent sympathetic skin responses, elevated thermal thresholds, worsened NCS profiles, and functional deficits of polyneuropathy. Interpretation Late‐onset ATTRv‐PN coexisted with cardiomyopathy regardless of the clinical severity of polyneuropathy. The cardiac amyloid burden revealed by CMR was correlated with pathophysiology and clinical disability of nerve degeneration.
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Affiliation(s)
- Yen-Hung Lin
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Hsueh-Wen Hsueh
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Mao-Yuan Su
- Department of Radiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Mei-Fang Cheng
- Department of Nuclear Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ming-Chang Chiang
- Department of Biomedical Engineering, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Jyh-Ming Jimmy Juang
- Department of Internal Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Yi-Hui Kao
- Department of Neurology, National Taiwan University Hospital Yunlin Branch, Yunlin, Taiwan
| | - Kai-Chieh Chang
- Department of Neurology, National Taiwan University Hospital Yunlin Branch, Yunlin, Taiwan
| | - Fang-Ping Feng
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Sung-Tsang Hsieh
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan.,Graduate Institute of Brain and Mind Sciences, National Taiwan University College of Medicine, Taipei, Taiwan.,Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan.,Center of Precision Medicine, National Taiwan University College of Medicine, Taipei, Taiwan
| | - Chi-Chao Chao
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
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46
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Porcari A, Fontana M, Gillmore JD. Transthyretin cardiac amyloidosis. Cardiovasc Res 2022; 118:3517-3535. [PMID: 35929637 PMCID: PMC9897687 DOI: 10.1093/cvr/cvac119] [Citation(s) in RCA: 46] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 06/16/2022] [Accepted: 06/26/2022] [Indexed: 02/06/2023] Open
Abstract
Transthyretin cardiac amyloidosis (ATTR-CA) is an increasingly recognized cause of heart failure (HF) and mortality worldwide. Advances in non-invasive diagnosis, coupled with the development of effective treatments, have shifted ATTR-CA from a rare and untreatable disease to a relatively prevalent condition that clinicians should consider on a daily basis. Amyloid fibril formation results from age-related failure of homoeostatic mechanisms in wild-type ATTR (ATTRwt) amyloidosis (non-hereditary form) or destabilizing mutations in variant ATTR (ATTRv) amyloidosis (hereditary form). Longitudinal large-scale studies in the United States suggest an incidence of cardiac amyloidosis in the contemporary era of 17 per 100 000, which has increased from a previous estimate of 0.5 per 100 000, which was almost certainly due to misdiagnosis and underestimated. The presence and degree of cardiac involvement is the leading cause of mortality both in ATTRwt and ATTRv amyloidosis, and can be identified in up to 15% of patients hospitalized for HF with preserved ejection fraction. Associated features, such as carpal tunnel syndrome, can preceed by several years the development of symptomatic HF and may serve as early disease markers. Echocardiography and cardiac magnetic resonance raise suspicion of disease and might offer markers of treatment response at a myocardial level, such as extracellular volume quantification. Radionuclide scintigraphy with 'bone' tracers coupled with biochemical tests may differentiate ATTR from light chain amyloidosis. Therapies able to slow or halt ATTR-CA progression and increase survival are now available. In this evolving scenario, early disease recognition is paramount to derive the greatest benefit from treatment.
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Affiliation(s)
- Aldostefano Porcari
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK,Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI), University of Trieste, Trieste 34149, Italy
| | - Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
| | - Julian D Gillmore
- Corresponding author. Tel: +44 2074332764; fax: +44 2044332817; E-mail:
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47
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Jaiswal V, Ang SP, Chia JE, Abdelazem EM, Jaiswal A, Biswas M, Gimelli A, Parwani P, Siller-Matula JM, Mamas MA. Echocardiographic predictors of presence of cardiac amyloidosis in aortic stenosis. Eur Heart J Cardiovasc Imaging 2022; 23:1290-1301. [PMID: 35925614 DOI: 10.1093/ehjci/jeac146] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 05/28/2022] [Accepted: 07/15/2022] [Indexed: 11/15/2022] Open
Abstract
AIMS Aortic stenosis (AS) and cardiac amyloidosis (CA) frequently coexist but the diagnosis of CA in AS patients remains a diagnostic challenge. We aim to evaluate the echocardiographic parameters that may aid in the detection of the presence of CA in AS patients. METHOD AND RESULTS We performed a systematic literature search of electronic databases for peer-reviewed articles from inception until 10 January 2022. Of the 1449 patients included, 160 patients had both AS-CA whereas the remaining 1289 patients had AS-only. The result of our meta-analyses showed that interventricular septal thickness [standardized mean difference (SMD): 0.74, 95% CI: 0.36-1.12, P = 0.0001), relative wall thickness (SMD: 0.74, 95% CI: 0.17-1.30, P < 0.0001), posterior wall thickness (SMD: 0.74, 95% CI 0.51 to 0.97, P = 0.0011), LV mass index (SMD: 1.62, 95% CI: 0.63-2.62, P = 0.0014), E/A ratio (SMD: 4.18, 95% CI: 1.91-6.46, P = 0.0003), and LA dimension (SMD: 0.73, 95% CI: 0.43-1.02, P < 0.0001)] were found to be significantly higher in patients with AS-CA as compared with AS-only patients. In contrast, myocardial contraction fraction (SMD: -2.88, 95% CI: -5.70 to -0.06, P = 0.045), average mitral annular S' (SMD: -1.14, 95% CI: -1.86 to -0.43, P = 0.0017), tricuspid annular plane systolic excursion (SMD: -0.36, 95% CI: -0.62 to -0.09, P = 0.0081), and tricuspid annular S' (SMD: -0.77, 95% CI: -1.13 to -0.42, P < 0.0001) were found to be significantly lower in AS-CA patients. CONCLUSION Parameters based on echocardiography showed great promise in detecting CA in patients with AS. Further studies should explore the optimal cut-offs for these echocardiographic variables for better diagnostic accuracy.
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Affiliation(s)
- Vikash Jaiswal
- Department of Cardiovascular Research, Larkin Community Hospital, South Miami, FL 33143, USA
| | - Song Peng Ang
- School of Medicine, International Medical University, Tawau 91000, Malaysia
| | - Jia Ee Chia
- School of Medicine, International Medical University, Tawau 91000, Malaysia
| | | | - Akash Jaiswal
- Department of Geriatric Medicine, All India Institute of Medical Science, New Delhi 110029, India
| | - Monodeep Biswas
- Division of Cardiology, Penn Medicine Lancaster General Health, Landisville, PA 17538, USA
| | - Alessia Gimelli
- Department of Imaging, Fondazione Toscana/CNR Gabriele Monasterio, Pisa 56124, Italy
| | - Purvi Parwani
- Division of Cardiology, Department of Medicine, Loma Linda University Health, Loma Linda, CA 92350, USA
| | - Jolanta M Siller-Matula
- Department of Cardiology, Medical University of Vienna, Vienna 1090, Austria.,Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Center for Preclinical Research and Technology CEPT, Warsaw 02-091, Poland
| | - Mamas A Mamas
- Keele Cardiovascular Research Group, Keele University, Keele ST5 5BG, UK
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48
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Shah S, Segar MW, Kondamudi N, Ayers C, Chandra A, Matulevicius S, Agusala K, Peshock R, Abbara S, Michos ED, Drazner MH, Lima JAC, Longstreth WT, Pandey A. Supranormal Left Ventricular Ejection Fraction, Stroke Volume, and Cardiovascular Risk: Findings From Population-Based Cohort Studies. JACC. HEART FAILURE 2022; 10:583-594. [PMID: 35902163 DOI: 10.1016/j.jchf.2022.05.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 04/18/2022] [Accepted: 05/04/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Supranormal ejection fraction by echocardiography in clinically referred patient populations has been associated with an increased risk of cardiovascular disease (CVD). The prognostic implication of supranormal left ventricular ejection fraction (LVEF)-assessed by cardiac magnetic resonance (CMR)-in healthy, community-dwelling individuals is unknown. OBJECTIVES The purpose of this study is to investigate the prognostic implication of supranormal LVEF as assessed by CMR and its inter-relationship with stroke volume among community-dwelling adults without CVD. METHODS Participants from the MESA (Multi-Ethnic Study of Atherosclerosis) and DHS (Dallas Heart Study) cohorts free of CVD who underwent CMR with LVEF above the normal CMR cutoff (≥57%) were included. The association between cohort-specific LVEF categories and risk of clinically adjudicated major adverse cardiovascular events (MACE) was assessed using adjusted Cox models. Subgroup analysis was also performed to evaluate the association of LVEF and risk of MACE among individuals stratified by left ventricular stroke volume index. RESULTS The study included 4,703 participants from MESA and 2,287 from DHS with 727 and 151 MACE events, respectively. In adjusted Cox models, the risk of MACE was highest among individuals in LVEF Q4 (vs Q1) in both cohorts after accounting for potential confounders (MESA: HR = 1.27 [95% CI: 1.01-1.60], P = 0.04; DHS: HR = 1.72 [95% CI: 1.05-2.79], P = 0.03). A significant interaction was found between the continuous measures of LVEF and left ventricular stroke volume index (P interaction = 0.02) such that higher LVEF was significantly associated with an increased risk of MACE among individuals with low but not high stroke volume. CONCLUSIONS Among community-dwelling adults without CVD, LVEF in the supranormal range is associated with a higher risk of adverse cardiovascular outcomes, particularly in those with lower stroke volume.
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Affiliation(s)
- Sonia Shah
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Matthew W Segar
- Department of Cardiology, Texas Heart Institute, Houston, Texas, USA
| | - Nitin Kondamudi
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Colby Ayers
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Alvin Chandra
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Susan Matulevicius
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Kartik Agusala
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Ron Peshock
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Suhny Abbara
- Department of Radiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Erin D Michos
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mark H Drazner
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Joao A C Lima
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - W T Longstreth
- Departments of Neurology and Epidemiology, University of Washington, Seattle, Washington, USA
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA.
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49
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Blood Cancer and the Heart: Light Chain Cardiomyopathy in Refractory Multiple Myeloma. Case Rep Cardiol 2022; 2022:7846846. [PMID: 35942233 PMCID: PMC9356901 DOI: 10.1155/2022/7846846] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 06/27/2022] [Accepted: 07/12/2022] [Indexed: 01/15/2023] Open
Abstract
We report a case of a 57-year-old woman with a history of multiple myeloma (MM) and light chain (AL) amyloidosis who presented due to worsening dyspnea on exertion. Her MM has been refractory to multiple chemotherapy regimens and two autologous bone marrow transplantation. Diagnostic evaluations including serum kappa and lambda chains, echocardiogram, pyrophosphate cardiac scan, and cardiac magnetic resonance were indicative of a progression to AL cardiomyopathy. Addition of daratumumab to her regimen appeared to ameliorate the progression of AL cardiomyopathy. However, it was stopped due to adverse effects of pancytopenia and allergic reactions including skin rash and hives. She was hospitalized for heart failure exacerbation and died approximately 2 months following the discontinuation of daratumumab. This case highlights the late presentation of AL cardiomyopathy in refractory MM.
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50
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Chacko L, Karia N, Venneri L, Bandera F, Dal Passo B, Buonamici L, Lazari J, Ioannou A, Porcari A, Patel R, Razvi Y, Brown J, Knight D, Martinez-Naharro A, Whelan C, Quarta CC, Manisty C, Moon J, Rowczenio D, Gilbertson JA, Lachmann H, Wechelakar A, Petrie A, Moody WE, Steeds RP, Potena L, Riefolo M, Leone O, Rapezzi C, Hawkins PN, Gillmore JD, Fontana M. Progression of echocardiographic parameters and prognosis in ATTR cardiac amyloidosis. Eur J Heart Fail 2022; 24:1700-1712. [PMID: 35779241 PMCID: PMC10108569 DOI: 10.1002/ejhf.2606] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 06/30/2022] [Accepted: 07/01/2022] [Indexed: 11/08/2022] Open
Abstract
AIMS Transthyretin amyloid cardiomyopathy (ATTR-CM) is an increasingly diagnosed disease. Echocardiography is widely utilized, but studies to confirm the value of echocardiography for tracking changes over time are not available. We sought to describe: (1) changes in multiple echocardiographic parameters; (2) differences in rate of progression of three predominant genotypes; and (3) the ability of changes in echocardiographic parameters to predict prognosis. METHODS AND RESULTS We prospectively studied 877 ATTR-CM patients attending our centre between 2000 and 2020. Serial echocardiography findings at baseline, 12-months and 24-months were compared with survival. Five-hundred-and-sixty-five patients had wild-type ATTR-CM and 312 hereditary ATTR-CM (201 with V122I; 90 with T60A).There was progressive worsening of structural and functional parameters over time, patients with V122I ATTR-CM showing more rapid worsening of left and right ventricular structural and functional parameters compared to both wild-type and T60A ATTR-CM. Among a wide range of echocardiographic analyses, including deformation-based parameters, only worsening in the degree of mitral and tricuspid regurgitation (MR and TR) at 12-and 24 month assessments was associated with worse prognosis (change at 12-months: MR, hazard ratio 1.43 (1.14-1.80,p=0.002); TR, hazard ratio 1.38 (1.10-1.75,p=0.006). Worsening in MR remained independently associated with poor prognosis after adjusting for known predictors. CONCLUSION In ATTR-CM, echocardiographic parameters progressively worsen over time. Patients with V122I ATTR-CM demonstrate the most rapid deterioration. Worsening of MR and TR were the only parameters associated with mortality, MR remaining independent after adjusting for known predictors. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Liza Chacko
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Nina Karia
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Lucia Venneri
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Francesco Bandera
- Heart Failure Unit, Cardiology University Department, IRCCS Policlinico San Donato, Piazza Malan, 1, San Donato Milanese, Milan, 20097, Italy.,Department for Biomedical Sciences for Health, University of Milano, Via Luigi, Mangiagalli, 31, Milan, 20133, Italy
| | - Beatrice Dal Passo
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Lodovico Buonamici
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Jonathan Lazari
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Adam Ioannou
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Aldostefano Porcari
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Rishi Patel
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Yousuf Razvi
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - James Brown
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Daniel Knight
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Ana Martinez-Naharro
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Carol Whelan
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Candida C Quarta
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Charlotte Manisty
- Barts Heart Centre, The Cardiovascular Magnetic Resonance Imaging Unit, and the Inherited Cardiovascular Diseases Unit, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
| | - James Moon
- Barts Heart Centre, The Cardiovascular Magnetic Resonance Imaging Unit, and the Inherited Cardiovascular Diseases Unit, St Bartholomew's Hospital, West Smithfield, London, EC1A 7BE, UK
| | - Dorota Rowczenio
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Janet A Gilbertson
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Helen Lachmann
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Ashutosh Wechelakar
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Aviva Petrie
- Eastman Dental Institute, University College London, Grays Inn Road, London, WC1X 8LD, UK
| | - William E Moody
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, B15 2TH, UK
| | - Richard P Steeds
- Department of Cardiology, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust and University of Birmingham, B15 2TH, UK
| | - Luciano Potena
- Division of Cardiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Mattia Riefolo
- Division of Pathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Ornella Leone
- Division of Pathology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Claudio Rapezzi
- Cardiologic Center, University of Ferrara, Italy.,Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Philip N Hawkins
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Julian D Gillmore
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Marianna Fontana
- National Amyloidosis Centre, Division of Medicine, University College London, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
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