Extracellular Volume Detects Amyloidotic Cardiomyopathy and Correlates With Neurological Impairment in Transthyretin-familial Amyloidosis

Senile Systemic Amyloidosis Presenting as Hematuria: A Rare Presentation and Review of Literature

Introduction

Senile systemic amyloidosis is a multisystem disease where wild-type insoluble transthyretin (ATTRwt) protein gets deposited in the tissues leading to organ dysfunction.

Methodology

We present the case of a patient who presented with hematuria and bladder involvement by ATTRwt amyloidosis who ultimately died of multiorgan failure.

Results

The patient was an 82-year-old white male with a history of ischemic cardiomyopathy (ejection fraction (EF): 20–25%), chronic atrial fibrillation, chronic kidney disease (CKD), and carpal tunnel syndrome who presented with acute hematuria, urinary retention, and progressive fatigue. He underwent cystoscopy and bladder biopsy which was positive on congo-red stain diagnostic for amyloidosis. Echocardiogram demonstrated worsening of EF to 10–15% and concentric left ventricle hypertrophy. MRI was not performed due to underlying CKD. His condition deteriorated during the hospital stay, and he developed cardiogenic shock and progressive liver dysfunction. Infectious workup was negative. Meanwhile, the biochemical investigations (serum protein electrophoresis, immunofixation, and urine kappa/lambda chains) ruled out plasma cell dyscrasias. Mass spectrometry analysis of the bladder biopsy specimen confirmed wild-type transthyretin (ATTRwt) amyloidosis consistent with senile systemic amyloidosis. Due to patients' extremely poor prognosis, his family wished to focus on patient's comfort-oriented measures only, and patient passed away shortly thereafter.

Conclusion

Senile systemic amyloidosis can rarely present in an atypical fashion such as hematuria. The treatment options are limited in this disease process. Novel therapies are in the early phases of development. Concern also exists that in patients with multiple comorbidities, this entity is under recognized until the more advanced stages.

Native T1 reference values for nonischemic cardiomyopathies and populations with increased cardiovascular risk: A systematic review and meta-analysis

Background

Although cardiac MR and T₁ mapping are increasingly used to diagnose diffuse fibrosis based cardiac diseases, studies reporting T₁ values in healthy and diseased myocardium, particular in nonischemic cardiomyopathies (NICM) and populations with increased cardiovascular risk, seem contradictory.

Purpose

To determine the range of native myocardial T₁ value ranges in patients with NICM and populations with increased cardiovascular risk.

Study Type

Systemic review and meta‐analysis.

Population

Patients with NICM, including hypertrophic cardiomyopathy (HCM) and dilated cardiomyopathy (DCM), and patients with myocarditis (MC), iron overload, amyloidosis, Fabry disease, and populations with hypertension (HT), diabetes mellitus (DM), and obesity.

Field Strength/Sequence

(Shortened) modified Look–Locker inversion‐recovery MR sequence at 1.5 or 3T.

Assessment

PubMed and Embase were searched following the PRISMA guidelines.

Statistical Tests

The summary of standard mean difference (SMD) between the diseased and a healthy control populations was generated using a random‐effects model in combination with meta‐regression analysis.

Results

The SMD for HCM, DCM, and MC patients were significantly increased (1.41, 1.48, and 1.96, respectively, P < 0.01) compared with healthy controls. The SMD for HT patients with and without left‐ventricle hypertrophy (LVH) together was significantly increased (0.19, P = 0.04), while for HT patients without LVH the SMD was zero (0.03, P = 0.52). The number of studies on amyloidosis, iron overload, Fabry disease, and HT patients with LVH did not meet the requirement to perform a meta‐analysis. However, most studies reported a significantly increased T₁ for amyloidosis and HT patients with LVH and a significant decreased T₁ for iron overload and Fabry disease patients.

Data Conclusions

Native T₁ mapping by using an (Sh)MOLLI sequence can potentially assess myocardial changes in HCM, DCM, MC, iron overload, amyloidosis, and Fabry disease compared to controls. In addition, it can help to diagnose left‐ventricular remodeling in HT patients.

Level of Evidence: 2

Technical Efficacy: Stage 3

J. Magn. Reson. Imaging 2018;47:891–912.

Myocardial iodine concentration measurement using dual-energy computed tomography for the diagnosis of cardiac amyloidosis: a pilot study

OBJECTIVE

To measure myocardium iodine concentration (MIC) in patients with cardiac amyloidosis (CA) using dual-energy computed tomography (DECT).

METHODS

Twenty-two patients with CA, 13 with non-amyloid hypertrophic cardiomyopathies (CH) and 10 control patients were explored with pre-contrast, arterial and 5-minute DECT acquisition (Iomeprol; 1.5 mL/kg). Inter-ventricular septum (IVS) thickness, blood pool iodine concentration (BPIC), MIC (mg/mL), iodine ratio and extra-cellular volume (ECV) were calculated.

RESULTS

IVS thickness was significantly (p < 0.001) higher in CA (17 ± 4 mm) and CH (15 ± 3 mm) patients than in control patients (10 ± 1 mm). CA patients exhibited significantly (p < 0.001) higher 5-minute MIC [2.6 (2.3-3.1) mg/mL], 5-minute iodine ratio (0.88 ± 0.12) and ECV (0.56 ± 0.07) than CH [1.7 (1.4-2.2) mg/mL, 0.57 ± 0.07 and 0.36 ± 0.05, respectively] and control patients [1.9 (1.7-2.4) mg/mL, 0.58 ± 0.07 and 0.35 ± 0.04, respectively). CH and control patients exhibited similar values (p = 0.9). The area under the curve of 5-minute iodine ratio for the differential diagnosis of CA from CH patients was 0.99 (0.73-1.0; p = 0.001). With a threshold of 0.65, the sensitivity and specificity of 5-minute iodine ratio were 100% and 92%, respectively.

CONCLUSION

Five-minute MIC and iodine ratio were increased in CA patients and exhibited best diagnosis performance to diagnose CA in comparison to other parameters.

KEY POINT

• Dual-energy computed tomography can be used to detect cardiac amyloidosis • Five-minute myocardial iodine concentration and iodine ratio increase in cardiac amyloidosis • Among iodine parameters, 5-minute iodine ratio has the best diagnosis performance.