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Duca F, Rettl R, Kronberger C, Poledniczek M, Binder C, Dalos D, Koschutnik M, Donà C, Beitzke D, Loewe C, Nitsche C, Hengstenberg C, Badr-Eslam R, Kastner J, Bergler-Klein J, Kammerlander AA. Amyloid Burden Correlates with Electrocardiographic Findings in Patients with Cardiac Amyloidosis-Insights from Histology and Cardiac Magnetic Resonance Imaging. J Clin Med 2024; 13:368. [PMID: 38256502 PMCID: PMC10816127 DOI: 10.3390/jcm13020368] [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: 12/15/2023] [Revised: 12/28/2023] [Accepted: 01/05/2024] [Indexed: 01/24/2024] Open
Abstract
Cardiac amyloidosis (CA) is associated with several distinct electrocardiographic (ECG) changes. However, the impact of amyloid depositions on ECG parameters is not well investigated. We therefore aimed to assess the correlation of amyloid burden with ECG and test the prognostic power of ECG findings on outcomes in patients with CA. Consecutive CA patients underwent ECG assessment and cardiac magnetic resonance imaging (CMR), including the quantification of extracellular volume (ECV) with T1 mapping. Moreover, seven patients underwent additional amyloid quantification using immunohistochemistry staining of endomyocardial biopsies. A total of 105 CA patients (wild-type transthyretin: 74.3%, variant transthyretin: 8.6%, light chain: 17.1%) were analyzed for this study. We detected correlations of total QRS voltage with histologically quantified amyloid burden (r = -0.780, p = 0.039) and ECV (r = -0.266, p = 0.006). In patients above the ECV median (43.9%), PR intervals were significantly longer (p = 0.016) and left anterior fascicular blocks were more prevalent (p = 0.025). In our survival analysis, neither Kaplan-Meier curves (p = 0.996) nor Cox regression analysis detected associations of QRS voltage with adverse patient outcomes (hazard ratio: 0.995, p = 0.265). The present study demonstrated that an increased amyloid burden is associated with lower voltages in CA patients. However, baseline ECG findings, including QRS voltage, were not associated with adverse outcomes.
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Affiliation(s)
- Franz Duca
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - René Rettl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Christina Kronberger
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Michael Poledniczek
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Christina Binder
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Daniel Dalos
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Matthias Koschutnik
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Carolina Donà
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Dietrich Beitzke
- Division of Cardiovascular and Interventional Radiology, Department of Bioimaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria; (D.B.); (C.L.)
| | - Christian Loewe
- Division of Cardiovascular and Interventional Radiology, Department of Bioimaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria; (D.B.); (C.L.)
| | - Christian Nitsche
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Christian Hengstenberg
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Roza Badr-Eslam
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Johannes Kastner
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Jutta Bergler-Klein
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Andreas Anselm Kammerlander
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
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Aimo A, Camerini L, Fabiani I, Morfino P, Panichella G, Barison A, Pucci A, Castiglione V, Vergaro G, Sinagra G, Emdin M. Valvular heart disease in patients with cardiac amyloidosis. Heart Fail Rev 2024; 29:65-77. [PMID: 37735319 PMCID: PMC10904406 DOI: 10.1007/s10741-023-10350-1] [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] [Accepted: 09/13/2023] [Indexed: 09/23/2023]
Abstract
Cardiac amyloidosis (CA) is an underdiagnosed condition caused by the deposition of misfolded proteins, namely immunoglobulin light chains and transthyretin, in the extracellular spaces of the heart. Any cardiovascular structure can be affected by amyloid infiltration, including the valves. Amyloid accumulation within the cardiac valves may lead to their structural and functional impairment, with a profound impact on patients' prognosis and quality of life. The most common forms of valvular disease in CA are aortic stenosis (AS), mitral regurgitation (MR), and tricuspid regurgitation (TR). CA and AS share similar risk factors, disease mechanisms, and remodeling patterns, which make their diagnosis particularly challenging. Patients with both CA and AS experience worse outcomes than CA or AS alone, and transcatheter aortic valve replacement may represent a useful therapeutic strategy in this population. Data on MR and TR are quite limited and mainly coming from case reports or small series. This review paper will summarize our current understanding on the epidemiology, disease mechanisms, echocardiographic features, clinical implications, and therapeutic options of AS, MR, and TR in patients with CA.
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Affiliation(s)
- Alberto Aimo
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, 56127, Pisa, Italy.
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy.
| | - Lara Camerini
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, 56127, Pisa, Italy
| | - Iacopo Fabiani
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Paolo Morfino
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, 56127, Pisa, Italy
| | - Giorgia Panichella
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, 56127, Pisa, Italy
| | - Andrea Barison
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, 56127, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Angela Pucci
- Histopathology Department, University Hospital of Pisa, Pisa, Italy
| | - Vincenzo Castiglione
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, 56127, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Giuseppe Vergaro
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, 56127, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Gianfranco Sinagra
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Trieste, Italy
| | - Michele Emdin
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Piazza Martiri della Libertà 33, 56127, Pisa, Italy
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
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Gharbin J, Winful A, Alebna P, Grewal N, Brgdar A, Rhodd S, Taha M, Fatima U, Mehrotra P, Onwuanyi A. Trends in incidence and clinical outcome of non-ST elevation myocardial infarction in patients with amyloidosis in the United States, 2010-2020. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2023; 35:100336. [PMID: 38511180 PMCID: PMC10945973 DOI: 10.1016/j.ahjo.2023.100336] [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: 10/16/2023] [Accepted: 10/18/2023] [Indexed: 03/22/2024]
Abstract
Study objective To assess temporal changes in clinical profile and in-hospital outcome of patients with amyloidosis presenting with non-ST elevation myocardial infarction, NSTEMI. Design/setting We conducted a retrospective observational study using the National Inpatient Sample (NIS) database from January 1, 2010, to December 31, 2020. Main outcomes Primary outcome of interest was trend in adjusted in-hospital mortality in patients with amyloidosis presenting with NSTEMI from 2010 to 2020. Our secondary outcomes were trend in rate of coronary revascularization, and trend in duration of hospitalization. Results We identified 272,896 hospitalizations for amyloidosis. There was a temporal increase in incidence of NSTEMI among patients aged 18-44 years from 15.5 % to 28.0 %, a reverse trend was observed in 45-64 years: 22.1 % to 17.7 %, p = 0.043. There was no statistically significant difference in rate of coronary revascularization from 2010 to 2020; 16.3 % to 14.2 %, p = 0.86. We observed an increased odds of all-cause in-hospital mortality in patients with NSTEMI compared to those without NSTEMI (aOR = 2.2, 95 % CI: 1.9-2.6, p < 0.001) but there was a decrease trend in mortality from 21.5 % to 11.3 %, p = 0.013 for trend. Hospitalization duration was also observed to decreased from 14.1 days to 10.9 days during the study period (p = 0.055 for trend). Conclusion In patients with amyloidosis presenting with NSTEMI, there was increased incidence of NSTEMI among young adults, a steady trend in coronary revascularization, and a decreasing trend of adjusted all-cause in-hospital mortality and length of hospitalization from 2010 to 2020 in the United States.
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Affiliation(s)
- John Gharbin
- Department of Internal Medicine, Howard University, Washington, DC, USA
| | - Adwoa Winful
- Medical University of South Carolina Health, Orangeburg, SC, USA
| | - Pamela Alebna
- Division of Cardiology, Virginia Commonwealth University, Virginia, USA
| | - Niyati Grewal
- Department of Internal Medicine, Howard University, Washington, DC, USA
| | - Ahmed Brgdar
- Division of Cardiology, Howard University, Washington, DC, USA
| | - Suchelis Rhodd
- Division of Cardiology, Howard University, Washington, DC, USA
| | - Mohammed Taha
- Division of Cardiology, Virginia Commonwealth University, Virginia, USA
| | - Urooj Fatima
- Division of Cardiology, Howard University, Washington, DC, USA
| | | | - Anekwe Onwuanyi
- Division of Cardiology, Morehouse School of Medicine, Atlanta, GA, USA
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Abrahamson EE, Padera RF, Davies J, Farrar G, Villemagne VL, Dorbala S, Ikonomovic MD. The flutemetamol analogue cyano-flutemetamol detects myocardial AL and ATTR amyloid deposits: a post-mortem histofluorescence analysis. Amyloid 2023; 30:169-187. [PMID: 36411500 PMCID: PMC10199962 DOI: 10.1080/13506129.2022.2141623] [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: 07/27/2022] [Revised: 10/06/2022] [Accepted: 10/21/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND [18F]flutemetamol is a PET radioligand used to image brain amyloid, but its detection of myocardial amyloid is not well-characterized. This histological study characterized binding of fluorescently labeled flutemetamol (cyano-flutemetamol) to amyloid deposits in myocardium. METHODS Myocardial tissue was obtained post-mortem from 29 subjects with cardiac amyloidosis including transthyretin wild-type (ATTRwt), hereditary/variant transthyretin (ATTRv) and immunoglobulin light-chain (AL) types, and from 10 cardiac amyloid-free controls. Most subjects had antemortem electrocardiography, echocardiography, SPECT and cardiac MRI. Cyano-flutemetamol labeling patterns and integrated density values were evaluated relative to fluorescent derivatives of Congo red (X-34) and Pittsburgh compound-B (cyano-PiB). RESULTS Cyano-flutemetamol labeling was not detectable in control subjects. In subjects with cardiac amyloidosis, cyano-flutemetamol labeling matched X-34- and cyano-PiB-labeled, and transthyretin- or lambda light chain-immunoreactive, amyloid deposits and was prevented by formic acid pre-treatment of myocardial sections. Cyano-flutemetamol mean fluorescence intensity, when adjusted for X-34 signal, was higher in the ATTRwt than the AL group. Cyano-flutemetamol integrated density correlated strongly with echocardiography measures of ventricular septal thickness and posterior wall thickness, and with heart mass. CONCLUSION The high selectivity of cyano-flutemetamol binding to myocardial amyloid supports the diagnostic utility of [18F]flutemetamol PET imaging in patients with ATTR and AL types of cardiac amyloidosis.
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Affiliation(s)
- Eric E. Abrahamson
- Geriatric Research Educational and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA 15213
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213
| | - Robert F. Padera
- Department of Pathology, Brigham and Women’s Hospital, Boston, MA 02115
| | | | | | - Victor L. Villemagne
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213
| | - Sharmila Dorbala
- Department of Radiology, Division of Nuclear Medicine and Molecular Imaging, Brigham and Women’s Hospital, Boston, MA 02115
| | - Milos D. Ikonomovic
- Geriatric Research Educational and Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA 15213
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA 15213
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Hassan R, Miller RJH, Howlett JG, White JA, Fine NM. Prevalence, incidence and clinical outcomes of epicardial coronary artery disease among transthyretin amyloidosis cardiomyopathy patients. BMC Cardiovasc Disord 2023; 23:124. [PMID: 36890444 PMCID: PMC9996970 DOI: 10.1186/s12872-023-03140-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 02/21/2023] [Indexed: 03/10/2023] Open
Abstract
BACKGROUND Transthyretin amyloidosis cardiomyopathy (ATTR-CM) patients are often older and may be at risk for obstructive epicardial coronary artery disease (oeCAD). While ATTR-CM may cause small vessel coronary disease, the prevalence and clinical significance of oeCAD is not well described. METHODS AND RESULTS The prevalence and incidence of oeCAD and its association with all-cause mortality and hospitalization among 133 ATTR-CM patients with ≥ 1-year follow-up was evaluated. The mean age was 78 ± 9 years, 119 (89%) were male, 116 (87%) had wild-type and 17 (13%) had hereditary subtypes. Seventy-two (54%) patients underwent oeCAD investigations, with 30 (42%) receiving a positive diagnosis. Among patients with a positive oeCAD diagnosis, 23 (77%) were diagnosed prior to ATTR-CM diagnosis, 6 (20%) at the time of ATTR-CM diagnosis, and 1 (3%) after ATTR-CM diagnosis. Baseline characteristics between patients with and without oeCAD were similar. Among patients with oeCAD, only 2 (7%) required additional investigations, intervention or hospitalization after ATTR-CM diagnosis. After a median follow-up of 27 months there were 37 (28%) deaths in the study population, including 5 patients with oeCAD (17%). Fifty-six (42%) patients in the study population required hospitalization, including 10 patients with oeCAD (33%). There was no significant difference in the rates of death or hospitalization among ATTR-CM patients with and without oeCAD, and oeCAD was not significantly associated with either outcome by univariable regression analysis. CONCLUSIONS While oeCAD is prevalent in ATTR-CM patients, this diagnosis is frequently known at time of ATTR-CM diagnosis and characteristics are similar to patients without oeCAD.
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Affiliation(s)
- Rana Hassan
- Division of Cardiology, Department of Cardiac Sciences, Alberta Health Services, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, South Health Campus, 4448 Front Street SE, Calgary Alberta, T3M 1M4, Canada
| | - Robert J H Miller
- Division of Cardiology, Department of Cardiac Sciences, Alberta Health Services, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, South Health Campus, 4448 Front Street SE, Calgary Alberta, T3M 1M4, Canada
| | - Jonathan G Howlett
- Division of Cardiology, Department of Cardiac Sciences, Alberta Health Services, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, South Health Campus, 4448 Front Street SE, Calgary Alberta, T3M 1M4, Canada
| | - James A White
- Division of Cardiology, Department of Cardiac Sciences, Alberta Health Services, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, South Health Campus, 4448 Front Street SE, Calgary Alberta, T3M 1M4, Canada
| | - Nowell M Fine
- Division of Cardiology, Department of Cardiac Sciences, Alberta Health Services, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, South Health Campus, 4448 Front Street SE, Calgary Alberta, T3M 1M4, Canada.
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Irabor B, McMillan JM, Fine NM. Assessment and Management of Older Patients With Transthyretin Amyloidosis Cardiomyopathy: Geriatric Cardiology, Frailty Assessment and Beyond. Front Cardiovasc Med 2022; 9:863179. [PMID: 35656395 PMCID: PMC9152087 DOI: 10.3389/fcvm.2022.863179] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 03/23/2022] [Indexed: 11/29/2022] Open
Abstract
Transthyretin amyloidosis cardiomyopathy (ATTR-CM) is commonly diagnosed in older adults, in particular the wild-type (ATTRwt), which is regarded as an age-related disease. With an aging population and improved diagnostic techniques, the prevalence and incidence of ATTR-CM will continue to increase. With increased availability of mortality reducing ATTR-CM therapies, patients are living longer. The predominant clinical manifestation of ATTR-CM is heart failure, while other cardiovascular manifestations include arrhythmia and aortic stenosis. Given their older age at diagnosis, patients often present with multiple age-related comorbidities, some of which can be exacerbated by ATTR, including neurologic, musculoskeletal, and gastrointestinal problems. Considerations related to older patient care, such as frailty, cognitive decline, polypharmacy, falls/mobility, functional capacity, caregiver support, living environment, quality of life and establishing goals of care are particularly important for many patients with ATTR-CM. Furthermore, the high cost ATTR treatments has increased interest in establishing improved predictors of response to therapy, with assessment of frailty emerging as a potentially important determinant. Multidisciplinary care inclusive of collaboration with geriatric and elder care medicine specialists, and others such as neurology, orthopedic surgery, electrophysiology and transcatheter aortic valve replacement clinics, is now an important component of ATTR-CM management. This review will examine current aspects of the management of older ATTR-CM patients, including shared care with multiple medical specialists, the emerging importance of frailty assessment and other considerations for using ATTR therapies.
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Affiliation(s)
| | - Jacqueline M. McMillan
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Division of Geriatrics, Departments of Medicine and Community Health Sciences, Calgary, AB, Canada
| | - Nowell M. Fine
- Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Division of Cardiology, Departments of Cardiac Sciences, Medicine and Community Health Sciences, Libin Cardiovascular Institute, Calgary, AB, Canada
- *Correspondence: Nowell M. Fine
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Singulane CC, Slivnick JA, Addetia K, Asch F, Sarswat N, Soulat-Dufour L, Mor-Avi V, Lang RM. Prevalence of Right Atrial Impairment and Association with Outcomes in Cardiac Amyloidosis. J Am Soc Echocardiogr 2022; 35:829-835.e1. [DOI: 10.1016/j.echo.2022.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2022] [Revised: 03/24/2022] [Accepted: 03/28/2022] [Indexed: 10/18/2022]
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Slivnick J, Zareba KM, Varghese J, Truong V, Wallner AL, Tong MS, Hummel C, Mazur W, Rajpal S. Prevalence and haemodynamic profiles of pulmonary hypertension in cardiac amyloidosis. Open Heart 2022; 9:openhrt-2021-001808. [PMID: 35246499 PMCID: PMC8900043 DOI: 10.1136/openhrt-2021-001808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Accepted: 01/09/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES While cardiac amyloidosis (CA) classically involves the left ventricle (LV), less is known about its impact on the right ventricle (RV) and pulmonary vasculature. We performed a retrospective analysis to identify the prevalence and types of pulmonary hypertension (PH) profiles in CA and to determine haemodynamic and cardiovascular magnetic resonance (CMR) predictors of major adverse cardiovascular events (MACE). METHODS Patients with CA who underwent CMR and right heart catheterisation (RHC) within 1 year between 2010 and 2019 were included. Patients were assigned the following haemodynamic profiles based on RHC: no PH, precapillary PH, isolated postcapillary PH (IPCPH), or combined precapillary and postcapillary PH (CPCPH). The relationship between PH profile and MACE (death, heart failure hospitalisation) was assessed using survival analysis. CMR and RV parameters were correlated with MACE using Cox-regression analysis. RESULTS A total of 52 patients were included (age 69±9 years, 85% men). RHC was performed during biopsy in 44 (85%) and for clinical indications in 8 (15%) patients. Rates of no PH, precapillary PH, IPCPH and CPCPH were 5 (10%), 3 (6%), 29 (55%) and 15 (29%), respectively. Haemodynamic PH profile did not correlate with risk of death (p=0.98) or MACE (p=0.67). Transpulmonary gradient (TPG) (HR 0.88, CI 0.80 to 0.97), RV, (HR 0.95, CI 0.92 to 0.98) and LV ejection fraction (HR 0.95, CI 0.92 to 0.98) were significantly associated with MACE. CONCLUSIONS PH is highly prevalent in CA, even at the time of diagnosis. While IPCPH was most common, CPCPH is not infrequent. TPG and RV ejection fraction (RVEF) are prognostic markers in this population.
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Affiliation(s)
- Jeremy Slivnick
- Cardiovascular Medicine, University of Chicago Medicine, Chicago, Illinois, USA
| | - Karolina M Zareba
- Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Juliet Varghese
- Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Vien Truong
- Cardiology, Christ Hospital, Cincinnati, Ohio, USA
| | - Alexander L Wallner
- Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Matthew S Tong
- Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Christopher Hummel
- Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | | | - Saurabh Rajpal
- Internal Medicine/Cardiology, Ohio State University Wexner Medical Center, Columbus, Ohio, USA.,Cardiology, Nationwide Children's Hospital Doctors Hospital Pediatric Residency Training Program, Columbus, Ohio, USA
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Uddin MM, Mir T, Kaur J, Pervaiz E, Babu MA, Sheikh M. ST-elevation myocardial infarction among cardiac amyloidosis patients; a national readmission database study. Heart Fail Rev 2022; 27:1579-1586. [DOI: 10.1007/s10741-021-10210-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/10/2021] [Indexed: 11/29/2022]
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10
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Tateishi Y, Yamada Y, Katsuki M, Nagata T, Yamamoto H, Kohashi K, Koga Y, Hashisako M, Kiyozawa D, Mori T, Kuboyama Y, Kakinokizono A, Miyazaki Y, Yamaguchi A, Tsutsui H, Ninomiya T, Naiki H, Oda Y. Pathological review of cardiac amyloidosis using autopsy cases in a single Japanese institution. Pathol Res Pract 2021; 227:153635. [PMID: 34653913 DOI: 10.1016/j.prp.2021.153635] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 09/23/2021] [Accepted: 09/24/2021] [Indexed: 10/20/2022]
Abstract
AIM Amyloidosis is a systemic or localized disease of protein deposition characterized by amorphous eosinophilic morphology and positivity of Congo Red staining. The typing of amyloidosis is becoming increasingly important because therapeutic agents for each amyloidosis type have been developed. Herein, the authors review the autopsy cases at an institution to reveal the putative Japanese characteristics of each amyloidosis type and evaluate the clinicopathological significance of each type. MATERIALS AND METHODS A total of 131 autopsy cases of systemic and localized amyloidosis were retrieved for classification by immunohistochemistry. Immunohistochemistry for transthyretin, amyloid A (AA), immunoglobulin light-chain kappa and lambda, and β2-microglobulin was performed for all cases. RESULTS The 131 amyloidosis cases were classified as follows: 71 cases (54.2%) of transthyretin amyloidosis, 32 cases (24.4%) of AA amyloidosis, 8 cases (6.1%) of light-chain amyloidosis, and 5 cases (3.8%) of β2-microglobulin amyloidosis, along with 15 equivocal cases (11.5%). All cases showed myocardial involvement of amyloidosis. Histopathologically, the transthyretin type was significantly associated with the interstitial and nodular patterns, and with the absence of the perivascular and endocardial patterns. The AA type was significantly associated with the perivascular and endocardial patterns, and with the absence of the nodular pattern. CONCLUSION The authors revealed the putative characteristics of cardiac amyloidosis in Japan by using autopsy cases. About 90% of amyloidosis cases were successfully classified using only commercially available antibodies.
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Affiliation(s)
- Yuki Tateishi
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka-ken 812-8582, Japan
| | - Yuichi Yamada
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka-ken 812-8582, Japan
| | - Masato Katsuki
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka-ken 812-8582, Japan
| | - Takuya Nagata
- Department of Epidemiology and Public Health, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka-ken 812-8582, Japan
| | - Hidetaka Yamamoto
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka-ken 812-8582, Japan
| | - Kenichi Kohashi
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka-ken 812-8582, Japan
| | - Yutaka Koga
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka-ken 812-8582, Japan
| | - Mikiko Hashisako
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka-ken 812-8582, Japan
| | - Daisuke Kiyozawa
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka-ken 812-8582, Japan
| | - Taro Mori
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka-ken 812-8582, Japan
| | - Yusuke Kuboyama
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka-ken 812-8582, Japan
| | - Ayumi Kakinokizono
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka-ken 812-8582, Japan
| | - Yoshiko Miyazaki
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka-ken 812-8582, Japan
| | - Aina Yamaguchi
- Department of Molecular Pathology, University of Fukui, 23-3 Matsuokashimoaizuki, Yoshida-gun Eiheiji-cho, Fukui-ken, Japan
| | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka-ken 812-8582, Japan
| | - Toshiharu Ninomiya
- Department of Epidemiology and Public Health, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka-ken 812-8582, Japan
| | - Hironobu Naiki
- Department of Molecular Pathology, University of Fukui, 23-3 Matsuokashimoaizuki, Yoshida-gun Eiheiji-cho, Fukui-ken, Japan
| | - Yoshinao Oda
- Department of Anatomic Pathology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka-shi, Fukuoka-ken 812-8582, Japan.
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Abstract
Cardiac amyloidosis, a form of infiltrative cardiomyopathy, is associated with poor prognosis in untreated patients. Early diagnosis is important for timely initiation of effective therapies. Despite advances in diagnostic modalities, it remains a challenging diagnosis, requiring high index of clinical suspicion. Echocardiography represents the first-line cardiac imaging modality for evaluation of heart failure and suspected cardiac amyloidosis. In this review, we discuss echocardiographic findings in cardiac amyloidosis.
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12
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Kichloo A, Jamal S, Albosta M, Khan MZ, Aljadah M, Edigin E, Amir R, Wani F, Ul-Haq E, Kanjwal K. Increased inpatient mortality in patients hospitalized for atrial fibrillation and atrial flutter with concomitant amyloidosis: Insight from National Inpatient Sample (NIS) 2016-2017. Indian Pacing Electrophysiol J 2021; 21:344-348. [PMID: 34153477 PMCID: PMC8577133 DOI: 10.1016/j.ipej.2021.06.005] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Revised: 05/31/2021] [Accepted: 06/16/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose Using National Inpatient Database (NIS), comparison of clinical outcomes for patients primarily admitted for atrial fibrillation/flutter with and without a secondary diagnosis of amyloidosis was done. Inpatient mortality was the primary outcome and hospital length of stay (LOS), mean total hospital charges, odds of undergoing cardiac ablation, pharmacologic cardioversion, having a secondary discharge diagnosis of heart block, cardiogenic shock and cardiac arrest were secondary outcomes. Methods NIS database of 2016, 2017 was used for only adult hospitalizations with atrial fibrillation/flutter as principal diagnosis with and without amyloidosis as secondary diagnosis using ICD-10 codes. Multivariate logistic with linear regression analysis was used to adjust for confounders. Results 932,054 hospitalizations were for adult patients with a principal discharge diagnosis of atrial fibrillation/flutter. 830 (0.09%) of these hospitalizations had amyloidosis. Atrial fibrillation/flutter hospitalizations with co-existing amyloidosis have higher inpatient mortality (4.22% vs 0.88%, AOR: 3.92, 95% CI 1.81–8.51, p = 0.001) and likelihood of having a secondary discharge diagnosis of cardiac arrest (2.40% vs 0.51%, AOR: 4.80, 95% CI 1.89–12.20, p = 0.001) compared to those without amyloidosis. Conclusions Hospitalizations of atrial fibrillation/flutter with co-existing amyloidosis have higher inpatient mortality and odds of having a secondary discharge diagnosis of cardiac arrest compared to those without amyloidosis. However, LOS, total hospital charges, likelihood of undergoing cardiac ablation, pharmacologic cardioversion, having a secondary discharge diagnosis of heart block and cardiogenic shock were similar between both groups.
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Affiliation(s)
- Asim Kichloo
- Central Michigan University College of Medicine, Saginaw, MI, USA; Samaritan Medical Center, Watertown, NY, USA.
| | - Shakeel Jamal
- Central Michigan University College of Medicine, Saginaw, MI, USA.
| | - Michael Albosta
- Central Michigan University College of Medicine, Saginaw, MI, USA.
| | | | | | | | - Rawan Amir
- University of Maryland School of Medicine, Baltimore, MD, USA.
| | - Farah Wani
- Samaritan Medical Center, Watertown, NY, USA.
| | - Ehtesham Ul-Haq
- University of Kentucky College of Medicine, Bowling Green, KY, USA.
| | - Khalil Kanjwal
- Michigan State University McLaren Greater Lansing Hospital, Lansing, MI, USA.
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13
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Jamal S, Kichloo A, Bailey B, Singh J, Virk H, Soni R, Wani F, Ajmal M, Ananthaneni S, Edigin E, Sudhakar R, Kanjwal K. Clinical Outcomes and Disease Burden in Amyloidosis Patients with and Without Atrial Fibrillation-Insight from the National Inpatient Sample Database. J Innov Card Rhythm Manag 2021; 12:4542-4549. [PMID: 34234988 PMCID: PMC8225306 DOI: 10.19102/icrm.2021.120605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 02/05/2021] [Indexed: 01/09/2023] Open
Abstract
Amyloidosis is a systemic illness that affects multiple organ systems, including the cardiovascular, renal, gastrointestinal, and pulmonary systems. Common manifestations include restrictive cardiomyopathy, arrhythmias, nephrotic syndrome, and gastrointestinal hemorrhage. It is unknown whether coexisting atrial fibrillation (AF) worsens the disease burden and outcomes in patients with systemic amyloidosis. In this study, those with a diagnosis of amyloidosis with and without coexisting AF were identified by querying the Healthcare Cost and Utilization Project—specifically, the National Inpatient Sample for the year 2016—based on International Classification of Diseases, 10th Revision, Clinical Modification codes. During 2016, a total of 2,997 patients were admitted with a diagnosis of amyloidosis, including 918 with concurrent AF. Greater rates of mortality (7.4% vs. 5.6%); heart block (6.8% vs. 2.8%); cardiogenic shock (5% vs. 1.6%); placement of an implantable cardioverter-defibrillator, cardiac resynchronization therapy device, or permanent pacemaker (14.5% vs. 4.5%); renal failure (29% vs. 21%); heart failure (66% vs. 30%); and bleeding complications (5.7% vs. 2.8%) were observed in patients with a diagnosis of amyloidosis and coexisting AF when compared with in patients without AF. Interestingly, patients with amyloidosis without comorbid AF had greater odds of associated stroke relative to those with concurrent AF (7.9% vs. 3.4%).
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Affiliation(s)
- Shakeel Jamal
- Department of Internal Medicine, Central Michigan University, College of Medicine, Saginaw, MI, USA
| | - Asim Kichloo
- Department of Internal Medicine, Central Michigan University, College of Medicine, Saginaw, MI, USA
| | - Beth Bailey
- Department of Internal Medicine, Central Michigan University, College of Medicine, Saginaw, MI, USA
| | - Jagmeet Singh
- Division of Nephrology, Geisinger Commonwealth School of Medicine, Scranton, PA, USA
| | - Hafeez Virk
- Division of Cardiovascular Medicine, Albert Einstein College of Medicine, Philadelphia, PA, USA
| | - Ronak Soni
- Division of Cardiovascular Medicine, University of Toledo, College of Medicine, Toledo, OH, USA
| | - Farah Wani
- Department of Internal Medicine, Samaritan Medical Center, Watertown, NY, USA
| | - Muhammad Ajmal
- Division of Cardiovascular Medicine, University of Arizona, College of Medicine, Tucson, AZ, USA
| | - Sindhura Ananthaneni
- Department of Internal Medicine, Central Michigan University, College of Medicine, Saginaw, MI, USA
| | - Ehizogie Edigin
- Department of Internal Medicine, John H Stroger Hospital of Cook County, Chicago, IL, USA
| | - Rajeev Sudhakar
- Division of Cardiovascular Medicine, Ascension Medical Group, Central Michigan University, Saginaw, MI, USA
| | - Khalil Kanjwal
- Division of Electrophysiology, McLaren Greater Lansing Hospital, Michigan State University, Lansing, MI, USA
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14
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Doost A, Arnolda L. Iodine staining outperforms phosphotungstic acid in high-resolution micro-CT scanning of post-natal mice cardiac structures. J Med Imaging (Bellingham) 2021; 8:027001. [PMID: 33778096 DOI: 10.1117/1.jmi.8.2.027001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 03/12/2021] [Indexed: 01/21/2023] Open
Abstract
Purpose: Micro-computed tomography (micro-CT) scan provides high-resolution three-dimensional images of mineralized tissues in small animal models. Contrast enhancement is essential to visualize non-mineralized tissues with micro-CT scan. We attempted to compare the two most common contrast agents to stain and image mouse cardiac structures. Approach: Ex-vivo micro-CT scan images of the mouse hearts were obtained following staining by potassium iodide or phosphotungstic acid (PTA). PTA-stained samples were imaged after various durations following staining (14 days, 25 days, 187 days, and 780 days), whereas iodine-stained samples were imaged after 72 hours. We compared median staining intensity between PTA and iodine at 0.1-mm intervals from the edge using the Mann Whitney test with correction for multiple comparisons. Results: Sixty post-natal mice hearts were stained with either PTA or iodine and imaged using micro-CT scan. Iodine proved to be faster and more uniform in complete enhancement of cardiac tissue in as short as 72 h, whereas PTA required a significantly longer time period to penetrate mouse cardiac structure ( > 150 days ). Median staining intensity with iodine was strongly higher than that with PTA from 0.1- to 1.5-mm distance from the epicardial edge (2-tailed P value < 0.01 or lower throughout). Conclusions: Iodine-stained soft tissue imaging by micro-CT scan provides a non-destructive, efficient, and accurate visualization tool for anatomical analysis of animal heart models of human cardiovascular conditions. Iodine is more efficient compared to PTA to achieve complete murine myocardial staining in a significantly shorter time period.
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Affiliation(s)
- Ata Doost
- Australian National University Medical School, Canberra, Australian Capital Territory, Australia.,Fiona Stanley Hospital, Cardiology Department, Murdoch, Western Australia, Australia
| | - Leonard Arnolda
- Australian National University Medical School, Canberra, Australian Capital Territory, Australia.,University of Wollongong, Illawarra Health and Medical Research Institute, Wollongong, New South Wales, Australia
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15
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Seth S, Agarwal H, Ghosh T, Arava S, Ray R. Cardiac amyloidosis in India: A clinicopathological study. JOURNAL OF THE PRACTICE OF CARDIOVASCULAR SCIENCES 2021. [DOI: 10.4103/jpcs.jpcs_35_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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16
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Visser RAB, Gravenor C, Ahmed S, Harky A. Amyloidosis and cardiovascular diseases: A clinical insight. J Card Surg 2020; 36:522-529. [PMID: 33283354 DOI: 10.1111/jocs.15230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 11/11/2020] [Indexed: 11/29/2022]
Abstract
Systemic amyloidosis is caused by the deposition of amyloid proteins in varying organ systems throughout the body, leading to dysfunction within those systems. The development of cardiac amyloidosis is one of the main indicators of poor prognosis in patients. Cardiac amyloidosis is most commonly caused by the immunoglobulin light chain amyloidosis and the transthyretin amyloidosis. Both have poor prognoses when associated with cardiac amyloidosis; however, the patients with the former subtype fair far worse than those with the latter. Despite amyloidosis having a history of being underdiagnosed, recent epidemiological data indicate that the rate of diagnosis has increased, which has coincided with improved in-patient median survival rates. It is of great importance that patients are diagnosed with the correct subtype as the main treatment strategy is to treat the underlying cause of amyloidosis. If a misdiagnosis is made, patients can receive treatment that might be ineffective or even harmful. A great progress has been made in pharmacological treatments for treating the underlying causes; however, many of the proposed treatments still need more evidence to support their use.
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Affiliation(s)
- Renier A B Visser
- School of Medicine, University of Central Lancashire, Preston, United Kingdom
| | - Céline Gravenor
- School of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Sennia Ahmed
- School of Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,Department of Cardiac Surgery, Alder Hey Children Hospital, Liverpool, United Kingdom.,Liverpool Centre of Cardiovascular Science, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
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17
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Dang D, Fournier P, Cariou E, Huart A, Ribes D, Cintas P, Roussel M, Colombat M, Lavie‐Badie Y, Carrié D, Galinier M, Lairez O. Gateway and journey of patients with cardiac amyloidosis. ESC Heart Fail 2020; 7:2418-2430. [PMID: 32588554 PMCID: PMC7524246 DOI: 10.1002/ehf2.12793] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2020] [Revised: 04/21/2020] [Accepted: 05/13/2020] [Indexed: 12/16/2022] Open
Abstract
AIMS Advances have been made over the last decade in the management of cardiac amyloidosis (CA), but a delayed diagnosis is still common. The aim of this study was to describe the journey to CA diagnosis from initial clinical and to analyse time to diagnosis. METHODS AND RESULTS Between January 2001 and May 2019, 270 consecutive patients with CA diagnosed at Toulouse University Hospital were retrospectively included in this cross-sectional study: 111 (41%) light chain amyloidosis, 122 (45%) wild-type transthyretin amyloidosis, and 37 (14%) hereditary transthyretin amyloidosis. CA onset occurred mostly with dyspnoea (50%) or systematic follow-up (10%). The cardiologist was the first line specialist in 68% of patients, followed by the nephrologist (9%) and neurologist (8%). Patients encountered a median (minimum-maximum) number of two (1-7) physician specialists and performed a median (minimum-maximum) number of three (1-8) tests before diagnosis. Median delay between symptom onset and CA diagnosis was 8 [IQR 5-14], 10 [IQR 3-34], and 18 [IQR 4-49] months, respectively, in light chain amyloidosis, wild-type transthyretin amyloidosis, and hereditary transthyretin amyloidosis subgroups (P = .060). Having performed electromyography or spirometry was associated with a longer delay in diagnosis in the overall population: odds ratio = 1.13; 95% confidence interval 1.02 to 1.24; and odds ratio = 1.13; 1.03 to 1.24, respectively, probably due to non-specific initial symptoms. CONCLUSIONS CA is a protean disease with various first line specialists causing a diagnostic wandering despite increasing medical community awareness. It requires a multidisciplinary specialist care networks to educate and manage symptoms and therapies.
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Affiliation(s)
- Daniel Dang
- Department of CardiologyRangueil University HospitalToulouseFrance
- Cardiac Imaging CenterToulouse University HospitalToulouseFrance
| | - Pauline Fournier
- Department of CardiologyRangueil University HospitalToulouseFrance
- Cardiac Imaging CenterToulouse University HospitalToulouseFrance
| | - Eve Cariou
- Department of CardiologyRangueil University HospitalToulouseFrance
- Cardiac Imaging CenterToulouse University HospitalToulouseFrance
| | - Antoine Huart
- Department of Nephrology and Referral Center for Rare DiseasesRangueil University HospitalToulouseFrance
| | - David Ribes
- Department of Nephrology and Referral Center for Rare DiseasesRangueil University HospitalToulouseFrance
| | - Pascal Cintas
- Department of NeurologyPurpan University HospitalToulouseFrance
| | | | | | - Yoan Lavie‐Badie
- Department of CardiologyRangueil University HospitalToulouseFrance
- Cardiac Imaging CenterToulouse University HospitalToulouseFrance
- Department of Nuclear MedicineToulouse University HospitalToulouseFrance
| | - Didier Carrié
- Department of CardiologyRangueil University HospitalToulouseFrance
- Cardiac Imaging CenterToulouse University HospitalToulouseFrance
- Medical SchoolToulouse III Paul Sabatier UniversityToulouseFrance
| | - Michel Galinier
- Department of CardiologyRangueil University HospitalToulouseFrance
- Cardiac Imaging CenterToulouse University HospitalToulouseFrance
- Medical SchoolToulouse III Paul Sabatier UniversityToulouseFrance
| | - Olivier Lairez
- Department of CardiologyRangueil University HospitalToulouseFrance
- Cardiac Imaging CenterToulouse University HospitalToulouseFrance
- Department of Nuclear MedicineToulouse University HospitalToulouseFrance
- Medical SchoolToulouse III Paul Sabatier UniversityToulouseFrance
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18
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Lever V, Erdini F, Ghimenton C, Novelli L, Brunelli M, Barbareschi M, Mazzoleni G, Vermiglio E, Mantovani A, Cima L, Valotto G, Eccher A. Pulmonary Fat Embolism and Coronary Amyloidosis. AMERICAN JOURNAL OF CASE REPORTS 2018; 19:744-747. [PMID: 29937538 PMCID: PMC6047570 DOI: 10.12659/ajcr.908561] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Patient: Male, 72 Final Diagnosis: Fat lung embolism Symptoms: Dyspnea Medication: — Clinical Procedure: — Specialty: Orthpedics and Traumatology
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Affiliation(s)
- Veronica Lever
- Pathology Unit, Department of Diagnostics and Public Health, University and Hospital Trust of Verona, Verona, Italy
| | - Francesco Erdini
- Pathology Unit, Department of Diagnostics and Public Health, University and Hospital Trust of Verona, Verona, Italy
| | - Claudio Ghimenton
- Pathology Unit, Department of Diagnostics and Public Health, University and Hospital Trust of Verona, Verona, Italy
| | - Luca Novelli
- Pathology Unit, Careggi University Hospital, Firenze, Italy
| | - Matteo Brunelli
- Pathology Unit, Department of Diagnostics and Public Health, University and Hospital Trust of Verona, Verona, Italy
| | | | | | - Elisa Vermiglio
- Forensic Pathology Unit,Department of Diagnostics and Public Health, University and Hospital Trust of Verona, Verona, Italy
| | - Alessandro Mantovani
- Division of Endocrinology, University and Hospital Trust of Verona, Verona, Italy
| | - Luca Cima
- Pathology Unit, Department of Diagnostics and Public Health, University and Hospital Trust of Verona, Verona, Italy
| | - Giovanni Valotto
- Pathology Unit, Department of Diagnostics and Public Health, University and Hospital Trust of Verona, Verona, Italy
| | - Albino Eccher
- Pathology Unit, Department of Diagnostics and Public Health, University and Hospital Trust of Verona, Verona, Italy
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Abstract
Cardiac amyloidosis is a group of disorders that develop secondary to the deposition of misfolded proteins in the heart. It can occur in isolation or as part of a systemic disease and can be inherited or acquired. Amyloid light chain (AL) and amyloid transthyretin (ATTR) are the two main forms of amyloid proteins that can infiltrate the heart. With the increased use of advanced imaging techniques and protocols, the recognition and diagnosis of cardiac amyloidosis, especially ATTR, has become easier. New therapies intended to improve survival and quality of life in patients with cardiac amyloidosis are emerging. This article provides an up-to-date review of cardiac amyloidosis.
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20
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Abstract
The heart and the kidneys are the most commonly involved organs in systemic amyloidosis. Cardiac involvement is associated with an increased morbidity, treatment intolerance, and poorer overall survival. The most common types of amyloidosis that are associated with cardiac involvement include light chain (AL) amyloidosis and transthyretin (TTR) amyloidosis (both mutant and wild type). The traditional first-line treatment for AL amyloidosis includes alkylator-based chemotherapy or high-dose melphalan followed by autologous stem cell transplantation (ASCT). Novel agents, including proteasome inhibitors, immunomodulators, and monoclonal antibodies, have shown promising activity in both frontline and relapsed settings. Orthotopic heart transplantation (OHT) followed by ASCT has led to superior outcomes compared to OHT alone. Orthotopic liver transplantation (OLT) is the first-line treatment for TTR amyloidosis. However, progression of cardiac amyloidosis after OLT is often noted due to deposition of wild TTR. Combined OLT and OHT also has a role in treatment and leads to superior outcomes in carefully selected candidates. Pharmacologic agents, including diflunisal, tafamidis, small interfering ribonucleic acid, and doxycycline, have shown promising activity in stabilizing TTR from misfolding into fibrils and are being actively investigated. Best supportive care and management of heart failure symptoms with diuretics are a mainstay of treatment in all cardiac amyloidosis subtypes. Robust data on the benefit of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or beta blockers in amyloid cardiomyopathy is lacking.
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Affiliation(s)
| | - Eli Muchtar
- Division of Hematology, Mayo Clinic, Rochester, MN, USA
| | - Morie A Gertz
- Division of Hematology, Mayo Clinic, Rochester, MN, USA.
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21
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Zhang C, Huang X, Li J. Light chain amyloidosis: Where are the light chains from and how they play their pathogenic role? Blood Rev 2017; 31:261-270. [PMID: 28336182 DOI: 10.1016/j.blre.2017.03.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2016] [Accepted: 03/03/2017] [Indexed: 12/17/2022]
Abstract
Amyloid light-chain (AL) amyloidosis is a plasma-cell dyscrasia, as well as the most common type of systematic amyloidosis. Pathogenic plasma cells that have distinct cytogenetic and molecular properties secrete an excess amount of amyloidogenic light chains. Assisted by post-translational modifications, matrix components, and other environmental factors, these light chains undergo a conformational change that triggers the formation of amyloid fibrils that overrides the extracellular protein quality control system. Moreover, the amyloidogenic light-chain itself is cytotoxic. As a consequence, organ dysfunction is caused by both organ architecture disruption and the direct cytotoxic effect of amyloidogenic light chains. Here, we reviewed the molecular mechanisms underlying this sequence of events that ultimately leads to AL amyloidosis and also discuss current in vitro and in vivo models, as well as relevant novel therapeutic approaches.
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Affiliation(s)
- Chunlan Zhang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Xufei Huang
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China
| | - Jian Li
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China.
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22
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Govender P, Keyes CM, Hankinson EA, O'Hara CJ, Sanchorawala V, Berk JL. Transbronchial biopsies safely diagnose amyloid lung disease. Amyloid 2017; 24:37-41. [PMID: 28393574 PMCID: PMC6014610 DOI: 10.1080/13506129.2017.1301917] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Autopsy identifies lung involvement in 58-92% of patients with the most prevalent forms of systemic amyloidoses. In the absence of lung biopsies, amyloid lung disease often goes unrecognized. Report of a death following transbronchial biopsies in a patient with systemic amyloidosis cautioned against the procedure in this patient cohort. We reviewed our experience with transbronchial biopsies in patients with amyloidosis to determine the safety and utility of bronchoscopic lung biopsies. METHODS We identified patients referred to the Amyloidosis Center at Boston Medical Center with lung amyloidosis diagnosed by transbronchial lung biopsies (TBBX). Amyloid typing was determined by immunohistochemistry or mass spectrometry. Standard end organ assessments, including pulmonary function test (PFT) and chest tomography (CT) imaging, and extra-thoracic biopsies established the extent of disease. RESULTS Twenty-five (21.7%) of 115 patients with lung amyloidosis were diagnosed by TBBX. PFT classified 33.3% with restrictive physiology, 28.6% with obstructive disease, and 9.5% mixed physiology; 9.5% exhibited isolated diffusion defects while 19% had normal pulmonary testing. Two view chest or CT imaging identified focal opacities in 52% of cases and diffuse interstitial disease in 48%. Amyloid type and disease extent included 68% systemic AL disease, 16% localized (lung limited) AL disease, 12% ATTR disease, and 4% AA amyloidosis. Fluoroscopy was not used during biopsy. No procedure complications were reported. CONCLUSIONS Our case series of 25 patients supports the use of bronchoscopic transbronchial biopsies for diagnosis of parenchymal lung amyloidosis. Normal PFTs do not rule out the histologic presence of amyloid lung disease.
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Affiliation(s)
- Praveen Govender
- a Pulmonary Center, Boston Medical Center , Boston , MA , USA.,b Department of Medicine , Boston Medical Center , Boston , MA , USA
| | | | | | - Carl J O'Hara
- e Amyloidosis Center, Boston Medical Center , Boston , MA , USA.,f Department of Pathology , Boston Medical Center , Boston , MA , USA
| | - Vaishali Sanchorawala
- b Department of Medicine , Boston Medical Center , Boston , MA , USA.,e Amyloidosis Center, Boston Medical Center , Boston , MA , USA
| | - John L Berk
- a Pulmonary Center, Boston Medical Center , Boston , MA , USA.,b Department of Medicine , Boston Medical Center , Boston , MA , USA.,e Amyloidosis Center, Boston Medical Center , Boston , MA , USA
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Ussavarungsi K, Yi ES, Maleszewski JJ, Kurtin PJ, Dasari S, Theis JD, Dispenzieri A, Ryu JH. Clinical relevance of pulmonary amyloidosis: an analysis of 76 autopsy-derived cases. Eur Respir J 2017; 49:49/2/1602313. [DOI: 10.1183/13993003.02313-2016] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 11/28/2016] [Indexed: 11/05/2022]
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Moore PT, Burrage MK, Mackenzie E, Law WP, Korczyk D, Mollee P. The Utility of 99mTc-DPD Scintigraphy in the Diagnosis of Cardiac Amyloidosis: An Australian Experience. Heart Lung Circ 2017; 26:1183-1190. [PMID: 28256403 DOI: 10.1016/j.hlc.2016.12.017] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2016] [Accepted: 12/19/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND The uptake of bone-seeking radiotracers in the amyloid heart is well recognised. 99mTc-DPD has been shown to be highly sensitive for cardiac transthyretin (ATTR) amyloid in an overseas population, but is not registered for use in Australia. We explored its utility as a diagnostic tool within our population. METHODS Patients diagnosed with AL and ATTR (wild-type and inherited) cardiac amyloidosis were prospectively recruited from the Princess Alexandra Hospital Amyloidosis Centre. Patients underwent injection with 99mTc-DPD then planar whole body imaging was performed at 5 minutes post-injection (soft tissue phase) and 3 hours (bone phase). A myocardial SPECT and low amperage CT were acquired after the late whole-body scan. Scans were analysed by two nuclear imaging specialists. Intensity of cardiac 99mTc-DPD uptake was graded as 0 to 3 in accordance with previous criteria, and semiquantitative analysis was performed using a heart to whole body ratio (H:WB) on the 3-hour scan. Patients also underwent electrocardiography and transthoracic echocardiography, and blood samples were taken for troponin I and brain natriuretic peptide levels, to assess for any correlation with DPD uptake. RESULTS Twenty-one patients (8 AL and 13 ATTR) completed the study. Median age was 58 and 70 years for AL and ATTR patients respectively, and 19 (90.5%) were male. 99mTc-DPD scintigraphy was positive in 2 (25%) of AL, and 13 (100%) of ATTR patients. Grade of cardiac uptake, and mean H:WB (0.1249 v. 0.0794) was greater in the ATTR cohort (p-value<0.001 and 0.001 respectively). No statistically significant correlation was identified between H:WB and echocardiographic parameters. There was a significant positive correlation between H:WB and the PR interval on ECG (p=0.026). CONCLUSIONS 99mTc-DPD scintigraphy is highly sensitive for the diagnosis of cardiac ATTR amyloid, but less so for AL amyloid.
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Affiliation(s)
- Peter T Moore
- Amyloidosis Centre, Princess Alexandra Hospital, Brisbane, Qld, Australia; School of Medicine, University of Queensland, Brisbane, Qld, Australia.
| | - Matthew K Burrage
- Amyloidosis Centre, Princess Alexandra Hospital, Brisbane, Qld, Australia; School of Medicine, University of Queensland, Brisbane, Qld, Australia
| | - Emily Mackenzie
- Amyloidosis Centre, Princess Alexandra Hospital, Brisbane, Qld, Australia; School of Medicine, University of Queensland, Brisbane, Qld, Australia
| | - W Philip Law
- Amyloidosis Centre, Princess Alexandra Hospital, Brisbane, Qld, Australia; School of Medicine, University of Queensland, Brisbane, Qld, Australia
| | - Dariusz Korczyk
- Amyloidosis Centre, Princess Alexandra Hospital, Brisbane, Qld, Australia; School of Medicine, University of Queensland, Brisbane, Qld, Australia
| | - Peter Mollee
- Amyloidosis Centre, Princess Alexandra Hospital, Brisbane, Qld, Australia; School of Medicine, University of Queensland, Brisbane, Qld, Australia
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Prevalence and prognostic impact of left-sided valve thickening in systemic light-chain amyloidosis. Clin Res Cardiol 2016; 106:331-340. [DOI: 10.1007/s00392-016-1058-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2016] [Accepted: 11/28/2016] [Indexed: 12/20/2022]
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Ong KC, Askew JW, Dispenzieri A, Maleszewski JJ, Klarich KW, Anavekar NS, Mulvagh SL, Grogan M. Abnormal stress echocardiography findings in cardiac amyloidosis. Amyloid 2016; 23:124-31. [PMID: 27132767 DOI: 10.1080/13506129.2016.1176020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND Cardiac involvement in immunoglobulin light chain (amyloid light chain, AL) amyloidosis is characterized by myocardial interstitial deposition but can also cause obstructive deposits in the coronary microvasculature. METHODS We retrospectively identified 20 patients who underwent stress echocardiography within 1 year prior to the histologic diagnosis of AL amyloidosis. Only patients with cardiac amyloidosis and no known obstructive coronary disease were included. RESULTS Stress echocardiograms (13 exercise; 7 dobutamine) were performed for evaluation of dyspnea and/or chest pain. Stress-induced wall motion abnormalities (WMAs) occurred in 11 patients (55%), 4 of whom had normal left ventricular wall thickness. Coronary angiogram was performed in 9 of 11 patients and demonstrated no or mild epicardial coronary artery disease. Seven (54%) patients had an abnormal exercise blood pressure which occurred with similar likelihood between those with and without stress-induced WMAs. CONCLUSIONS Stress-induced WMAs and abnormal exercise blood pressure may occur in patients with cardiac AL amyloidosis despite the absence of significant epicardial coronary artery disease. This finding should raise the possibility of cardiac amyloidosis even in the absence of significant myocardial thickening.
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Diagnostic approach to cardiac amyloidosis: A case report. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2016. [DOI: 10.1016/j.repce.2016.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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28
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Diagnostic approach to cardiac amyloidosis: A case report. Rev Port Cardiol 2016; 35:305.e1-7. [PMID: 27118142 DOI: 10.1016/j.repc.2016.01.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2013] [Revised: 11/09/2015] [Accepted: 01/22/2016] [Indexed: 11/20/2022] Open
Abstract
The authors present a case of systemic amyloidosis with cardiac involvement. We discuss the need for a high level of suspicion to establish a diagnosis, diagnostic techniques and treatment options. Our patient was a 78-year-old man with chronic renal disease and atrial fibrillation admitted with acute decompensated heart failure of unknown cause. The transthoracic echocardiogram revealed severely impaired left ventricular function with phenotypic overlap between hypertrophic and restrictive cardiomyopathy. After an extensive diagnostic workup, which included an abdominal fat pad biopsy, the final diagnosis was amyloidosis.
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Larsen BT, Mereuta OM, Dasari S, Fayyaz AU, Theis JD, Vrana JA, Grogan M, Dogan A, Dispenzieri A, Edwards WD, Kurtin PJ, Maleszewski JJ. Correlation of histomorphological pattern of cardiac amyloid deposition with amyloid type: a histological and proteomic analysis of 108 cases. Histopathology 2015. [PMID: 26212778 DOI: 10.1111/his.12793] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
AIMS Prognostication and treatment selection for cardiac amyloidosis requires accurate amyloid typing. The aim of this study was to investigate the utility of histomorphology for predicting type. METHODS AND RESULTS Autopsy cases with cardiac amyloidosis (1998-2010) were typed by the use of mass spectrometry-based proteomics. Deposition patterns were correlated with amyloid type. Among 108 decedents (mean age 75 years; 69% men), 107 had a single type, including transthyretin (ATTR) (60 cases), amyloid light chain (AL) (32 λ; 12 κ), amyloid A (AA) (two), and apolipoprotein AIV (AApoAIV) (one). Interstitial deposition was more extensive in AL amyloidosis cases than in ATTR cases [odds ratio (OR) 6.8, P = 0.0004]. Histomorphological patterns of interstitial deposition were mixed in 61% of AL amyloidosis cases and in 61% of ATTR cases, but diffuse pericellular deposits favoured AL amyloidosis (OR 10.7, P = 0.0001), nodular deposits favoured ATTR (OR 3.1, P = 0.0229), and discrete pericellular deposits tended to partially favour ATTR (OR 1.7, P = 0.1970). Arterial and venous deposits each favoured AL amyloidosis (OR ranging from 9.3 to 192.0, P-value ranging from 0.0022 to <0.0001), and were severe in AL amyloidosis. Endocardial deposits favoured AL amyloidosis (OR 46.3, P < 0.0001) and were also more severe in AL amyloidosis. CONCLUSIONS The extent and distribution of cardiac amyloidosis strongly correlate with amyloid type, suggesting fundamental differences in the pathobiology of deposition. The tendency for mixed patterns to occur limits the practicality and accuracy of using histopathology for amyloid typing.
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Affiliation(s)
- Brandon T Larsen
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN, USA.,Department of Pathology, University of Arizona, Tucson, AZ, USA
| | - Oana M Mereuta
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN, USA.,Division of Hematopathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Surendra Dasari
- Department of Health Sciences Research, Mayo Clinic, Rochester, MN, USA
| | - Ahmed U Fayyaz
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN, USA
| | - Jason D Theis
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN, USA
| | - Julie A Vrana
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN, USA
| | - Martha Grogan
- Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Ahmet Dogan
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN, USA.,Division of Hematopathology, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | | | - William D Edwards
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN, USA.,Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
| | - Paul J Kurtin
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN, USA
| | - Joseph J Maleszewski
- Department of Laboratory Medicine & Pathology, Mayo Clinic, Rochester, MN, USA.,Division of Cardiovascular Diseases, Mayo Clinic, Rochester, MN, USA
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Krishnan U, Mark TM, Niesvizky R, Sobol I. Pulmonary hypertension complicating multiple myeloma. Pulm Circ 2015; 5:590-7. [PMID: 26401262 PMCID: PMC4556512 DOI: 10.1086/682430] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2014] [Accepted: 04/08/2015] [Indexed: 12/15/2022] Open
Abstract
Pulmonary hypertension (PH) is an infrequently reported complication of multiple myeloma (MM). PH has been more commonly associated with amyloidosis, myeloproliferative diseases, and the POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal protein, skin changes) syndrome. PH in MM is typically mild to moderate and may be secondary to a variety of conditions, which include left ventricular dysfunction, high-output cardiac failure, chronic kidney disease, treatment-related toxicities, and precapillary involvement. We describe 3 patients with MM and severe PH. Each patient underwent right heart catheterization. All patients demonstrated elevated pulmonary pressures, transpulmonary gradients, and pulmonary vascular resistance. Each patient was ultimately treated with pulmonary vasodilator therapy with improvement in cardiopulmonary symptoms. Additional studies are needed to define the prevalence, prognosis, and pathogenesis of PH in this complex population and to help clarify who may benefit from targeted PH therapy.
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Affiliation(s)
- Udhay Krishnan
- Division of Cardiology, Weil Cornell Medical College, New York Presbyterian Hospital-Cornell Medical Center, New York, New York, USA
| | - Tomer M. Mark
- Division of Hematology and Medical Oncology, Weil Cornell Medical College, New York Presbyterian Hospital-Cornell Medical Center, New York, New York, USA
| | - Ruben Niesvizky
- Division of Hematology and Medical Oncology, Weil Cornell Medical College, New York Presbyterian Hospital-Cornell Medical Center, New York, New York, USA
| | - Irina Sobol
- Division of Cardiology, Weil Cornell Medical College, New York Presbyterian Hospital-Cornell Medical Center, New York, New York, USA
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Kwong RY, Heydari B, Abbasi S, Steel K, Al-Mallah M, Wu H, Falk RH. Characterization of Cardiac Amyloidosis by Atrial Late Gadolinium Enhancement Using Contrast-Enhanced Cardiac Magnetic Resonance Imaging and Correlation With Left Atrial Conduit and Contractile Function. Am J Cardiol 2015; 116:622-9. [PMID: 26076990 DOI: 10.1016/j.amjcard.2015.05.021] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2015] [Revised: 05/15/2015] [Accepted: 05/15/2015] [Indexed: 12/25/2022]
Abstract
The diagnosis of cardiac amyloidosis (CA) often necessitates invasive myocardial biopsy. We sought to evaluate whether late gadolinium enhancement (LGE) of the atrial myocardium by cardiac magnetic resonance imaging was associated with impaired left atrial (LA) function and whether the extent of LA LGE may enhance diagnostic differentiation of CA from other cardiomyopathies. Twenty-two patients with biopsy-proven CA, 37 with systemic hypertension (SH), and 22 with nonischemic dilated cardiomyopathy (NIDC) underwent cardiac magnetic resonance imaging and echocardiographic evaluation. Patients with CA had greater minimal LA volume (57 ± 53 vs 24 ± 18 in SH and 19 ± 25% in NIDC, p = 0.003), and significantly lower total LA emptying function (19 ± 14 vs 40 ± 14 in SH and 33 ± 20% in NIDC, p = 0.0006). The mean proportion of atrial enhancement (LGELA%) was significantly greater in patients with CA than with SH and NIDC (59 ± 36% vs 7.4 ± 2.1 and 2.9 ± 9.0%, p <0.0001, respectively). There was also a strong inverse correlation between both active and total atrial emptying (r = -0.69, p = 0.001; r = -0.67, p = 0.01, respectively) with LGELA% for patients with CA. In multivariate regression analysis, LGELA% was the strongest adjusted predictor for CA diagnosis. Using receiver operating characteristic analysis, LGELA% ≥33% produced the greatest diagnostic utility for CA (sensitivity 76%, specificity 94%). Patients with CA may have extensive LGE of the LA myocardium, which is associated with marked reduction in LA emptying function. The extent of LA LGE was highly predictive for the diagnosis of CA.
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Comparison between (99m)Tc-diphosphonate imaging and MRI with late gadolinium enhancement in evaluating cardiac involvement in patients with transthyretin familial amyloid polyneuropathy. AJR Am J Roentgenol 2013; 200:W256-65. [PMID: 23436870 DOI: 10.2214/ajr.12.8737] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Cardiac involvement is not rare in systemic amyloidosis and is associated with poor prognosis. Both (99m)Tc-diphosphonate imaging and cardiac MRI with late gadolinium enhancement are considered valuable tools in revealing amyloid deposition in the myocardium; however, to our knowledge, no comparative study between the two techniques exists. We compared findings of these two techniques in patients with transthyretin-familial amyloid polyneuropathy (FAP). SUBJECTS AND METHODS Eighteen patients with transthyretin-FAP underwent (99m)Tc-diphosphonate imaging and MRI with late gadolinium enhancement. Images were visually evaluated by independent readers to determine the presence of radiotracer accumulation or late gadolinium enhancement-positive areas at the level of cardiac chambers. RESULTS Interobserver agreement ranged from moderate to very good for (99m)Tc-diphosphonate imaging findings and was very good for findings of MRI with late gadolinium enhancement. Left ventricle (LV) radiotracer uptake was found in 10 of 18 patients, whereas LV late gadolinium enhancement-positive areas were found in eight of 18 patients (χ(2) = 0.9; p = 0.343). One hundred fifty-nine LV segments showed (99m)Tc-diphosphonate accumulation, and 57 LV segments were late gadolinium enhancement positive (p < 0.0001). Radiotracer uptake was found in the right ventricle (RV) in eight patients and in both atria in five patients, whereas MRI showed that RV was involved in three patients and both atria in six patients; the differences were not statistically significant (RV, p = 0.07; atria, p = 1). Intermodality agreement between (99m)Tc-diphosphonate imaging and MRI ranged from fair to good. CONCLUSION Our study shows that, although (99m)Tc-diphosphonate imaging and MRI with late gadolinium enhancement have similar capabilities to identify patients with myocardial amyloid deposition, cardiac amyloid infiltration burden can be significantly underestimated by visual analysis of MRI with late gadolinium enhancement compared with (99m)Tc-diphosphonate imaging.
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Cho HJ, Yoon JY, Bae MH, Lee JH, Yang DH, Park HS, Cho Y, Chae SC, Jun JE. Familial Transthyretin Amyloidosis with Variant Asp38Ala Presenting with Orthostatic Hypotension and Chronic Diarrhea. J Cardiovasc Ultrasound 2012; 20:209-12. [PMID: 23346293 PMCID: PMC3542517 DOI: 10.4250/jcu.2012.20.4.209] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2012] [Revised: 10/04/2012] [Accepted: 11/21/2012] [Indexed: 11/22/2022] Open
Abstract
A 53-year-old man complained of orthostatic, non-rotating dizziness, and chronic watery diarrhea of several years duration. His nerve-conduction velocity test revealed peripheral sensory-motor polyneuropathy and he showed an autonomic function abnormality. Echocardiographic examination showed ventricular and atrial wall thickening with a granular "sparkling" appearance. Left ventricular systolic function was preserved but pseudonormal diastolic dysfunction was present. Coronary angiography showed normal coronary arteries and an endomyocardial biopsy revealed lesions consistent with cardiac amyloidosis. Colonoscopic biopsy also revealed the deposition of amyloid fibrils. Gene analysis found the transthyretin variant Asp38Ala. His son had same mutation, but three daughters did not. In conclusion, we report a case of familial transthyretin amyloidosis with Asp38Ala.
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Affiliation(s)
- Hyun Jun Cho
- Division of Cardiology, Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea
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Tei M, Uchida K, Mutsuga M, Chambers JK, Nakayama H. The binding of curcumin to various types of canine amyloid proteins. J Vet Med Sci 2011; 74:481-3. [PMID: 22083083 DOI: 10.1292/jvms.11-0420] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Curcumin is a constituent phenol compound of turmeric, and has been used as a dietary spice and Indian medicine. Curcumin has been reported to inhibit the formation of amyloid β fibrils and aggregation. In this study, the binding activity of curcumin to various types of canine amyloid was examined. Tissue samples used were lesions of AA, AL, amyloid of canine amyloid-producing odontogenic tumor (Aapot), and senile cardiovascular amyloid (ScA). Curcumin stained all types of amyloid. The binding of curcumin to AA, ScA, and AL was lost by the KMnO(4) treatment, but Aapot maintained the binding. These findings indicate that curcumin binds several types of amyloid, while the binding sites of amyloid molecules might be different from that of Congo red.
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Affiliation(s)
- Meina Tei
- Department of Veterinary Pathology, Graduate School of Agricultural and Life Sciences, The University of Tokyo, Tokyo 113-8657, Japan
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Singh V, Fishman JE, Alfonso CE. Primary systemic amyloidosis presenting as constrictive pericarditis. Cardiology 2011; 118:251-5. [PMID: 21757898 DOI: 10.1159/000329062] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2011] [Accepted: 04/26/2011] [Indexed: 11/19/2022]
Abstract
The most frequent presentation of cardiac amyloidosis is with endomyocardial deposition, and resultant restrictive cardiomyopathy. We present a case of primary systemic amyloidosis causing constrictive pericarditis (CP) and congestive heart failure without clinical evidence of endomyocardial deposition. A comprehensive evaluation by noninvasive and invasive studies facilitated the differentiation of CP from restrictive cardiomyopathy and the patient was effectively treated with pericardectomy. To our knowledge, this is the first documented case of primary systemic amyloidosis causing selective CP with successful antemortem diagnosis and treatment in a young man.
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Affiliation(s)
- Vikas Singh
- Leonard H. Miller School of Medicine, Cardiovascular Division, University of Miami, Miami, FL 33136, USA.
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MRI of cardiac involvement in transthyretin familial amyloid polyneuropathy. AJR Am J Roentgenol 2011; 195:W394-9. [PMID: 21098170 DOI: 10.2214/ajr.09.3721] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The purpose of this study was to evaluate cardiac MRI features in a group of patients with transthyretin familial amyloid polyneuropathy (FAP). SUBJECTS AND METHODS Sixteen patients with transthyretin FAP underwent 2D echocardiography with Doppler examination, cardiac MRI, and (99m)Tc-diphosphonate (DPD) scintigraphy. Four patients had peripheral polyneuropathy, three had carpal tunnel syndrome, one patient had symptoms and signs of heart failure, and eight patients had no symptoms but had a family history of FAP. At MRI, cardiac function parameters and delayed contrast enhancement findings were evaluated. RESULTS Six patients had cardiac radiotracer uptake at scintigraphy (FAP cardiac group), and 10 patients had no cardiac uptake (FAP noncardiac group). The FAP cardiac group included the four patients with peripheral neuropathy, one patient with carpal tunnel syndrome, and the only patient with heart failure. At MRI, abnormal contrast enhancement was found in all patients with positive scintigraphic findings and in no patient with negative scintigraphic findings. All patients had involvement of the left ventricle and other chambers or structures (atria, right ventricle, tricuspid valve leaflets). Left ventricular contrast enhancement was focal in four patients, subendocardial circumferential in one patient, and diffuse in one patient. The only patient with signs of heart failure had circumferential subendocardial enhancement. CONCLUSION Cardiac contrast-enhanced MRI can be used to identify cardiac amyloidosis in patients with FAP who do not have clinical signs of heart involvement. In these patients, the typical subendocardial circumferential pattern of contrast enhancement is rare. We observed unusual enhancement patterns as focal or diffuse left ventricular enhancement accompanied by enhancement of the atria, tricuspid valve, or right ventricle.
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High prevalence of amyloid in 150 surgically removed heart valves—a comparison of histological and clinical data reveals a correlation to atheroinflammatory conditions. Cardiovasc Pathol 2010; 19:228-35. [DOI: 10.1016/j.carpath.2009.04.005] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2008] [Revised: 04/03/2009] [Accepted: 04/14/2009] [Indexed: 11/22/2022] Open
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Amyloid in endomyocardial biopsies. Virchows Arch 2010; 456:523-32. [PMID: 20376481 DOI: 10.1007/s00428-010-0909-5] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2010] [Revised: 03/11/2010] [Accepted: 03/15/2010] [Indexed: 10/24/2022]
Abstract
The prognosis of cardiac amyloidosis depends on the nature and origin of the amyloid protein deposited. However, little is known about the prevalence and origin of amyloid in heart muscle biopsies. We therefore examined retrospectively the distribution and origin of amyloid in a consecutive series of endomyocardial biopsies. Endomyocardial biopsies with verified presence of amyloid from 101 patients were included. Amyloid was classified immunohistochemically in each of them. Our collective comprised 63 men and 38 women, with a mean age of 66 years (range 37-85 years). Cardiac amyloidosis was the most common of the AL (54 patients) or ATTR type (42 patients). In five individuals, amyloid remained unclassified. AL amyloidosis was subdivided into ALlambda (45 patients) and ALkappa amyloid (nine patients). AA amyloid was not found in any individual. The amount of amyloid was higher in AL than in ATTR amyloidosis. Genomic DNA was extracted and examined by DNA sequencing in 19 patients with ATTR amyloidosis. Five (26%) individuals carried TTR mutations (p.Val20Ile, p.Val30Met (twice), p.Asp39Val and p.Glu54Asp) and were classified as suffering from hereditary ATTR amyloidosis. Amyloid in endomyocardial biopsies is most commonly of immunoglobulin light chain origin, followed by non-hereditary and hereditary-type ATTR amyloid.
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Amyloidosis as a rare cause of dyspnea. COR ET VASA 2010. [DOI: 10.33678/cor.2010.047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Abstract
Amyloidosis is a clinical disorder caused by the extracellular deposition of misfolded, insoluble aggregated protein with a characteristic ss pleated sheet configuration that produces apple-green birefringence under polarized light when stained with Congo red dye. The spectrum of organ involvement can include the kidneys, heart, blood vessels, central and peripheral nervous systems, liver, intestines, lungs, eyes, skin, and bones. Cardiovascular amyloidosis can be primary, a part of systemic amyloidosis, or the result of chronic systemic disease elsewhere in the body. The most common presentations are congestive heart failure because of restrictive cardiomyopathy and conduction abnormalities. Recent developments in imaging techniques and extracardiac tissue sampling have minimized the need for invasive endomyocardial biopsy for amyloidosis. Cardiac amyloidosis management will vary depending on the subtype but consists of supportive treatment of cardiac related symptoms and reducing the amyloid fibrils formation attacking the underlying disease. Despite advances in treatment, the prognosis for patients with amyloidosis is still poor and depends on the underlying disease type. Early diagnosis of cardiac amyloidosis may improve outcomes but requires heightened suspicion and a systematic clinical approach to evaluation. Delays in diagnosis, uncertainties about the relative merits of available therapies, and difficulties in mounting large-scale clinical trials in rare disorders combine to keep cardiac amyloidosis a challenging problem. This review outlines current approaches to diagnosis, assessment of disease severity, and treatment of cardiac amyloidosis.
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Syed IS, Glockner JF, Feng D, Araoz PA, Martinez MW, Edwards WD, Gertz MA, Dispenzieri A, Oh JK, Bellavia D, Tajik AJ, Grogan M. Role of Cardiac Magnetic Resonance Imaging in the Detection of Cardiac Amyloidosis. JACC Cardiovasc Imaging 2010; 3:155-64. [DOI: 10.1016/j.jcmg.2009.09.023] [Citation(s) in RCA: 374] [Impact Index Per Article: 26.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2008] [Revised: 09/03/2009] [Accepted: 09/16/2009] [Indexed: 01/26/2023]
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Dattilo PB. Familial (ATTR) amyloidosis misdiagnosed as the primary (AL) variant: a case report. CASES JOURNAL 2009; 2:9295. [PMID: 20062619 PMCID: PMC2803959 DOI: 10.1186/1757-1626-2-9295] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/06/2009] [Accepted: 12/09/2009] [Indexed: 12/02/2022]
Abstract
Introduction Primary (AL) Amyloidosis is arguably the most recognizable variant of the disease with many classic signs. However, it has been argued that the Familial variant (ATTR) is actually more prevalent. It is less recognizable, however, as its spectrum of organ involvement is frequently much more limited. The two variants carry significantly different prognoses, have divergent treatment strategies, and very different implications for the family members of patients. There is now a small amount of data that would suggest Familial Amyloidosis may be misdiagnosed as the AL form 2-4% of the time as a result of laboratory error. Case presentation Herein a case of Familial Amyloidosis initially mistaken for the AL form based on a false positive laboratory result is presented. This case illustrates the high index of suspicion required for proper diagnosis of this rare disease. Conclusion Clinician awareness of the various forms of Amyloidosis and the potential for lab error is key to ensuring an accurate diagnosis. The two most common forms carry significantly different implications for treatment and for potential impact on relatives. A high index of suspicion is required particularly for the Familial form of Amyloidosis.
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Affiliation(s)
- Philip B Dattilo
- Division of Cardiology, University of Colorado, Denver, Denver, CO, USA
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Hemmingson LO, Eriksson P. Cardiac amyloidosis mimicking hypertrophic cardiomyopathy. ACTA MEDICA SCANDINAVICA 2009; 219:421-3. [PMID: 3716885 DOI: 10.1111/j.0954-6820.1986.tb03333.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Amyloid infiltration of the heart may frequently masquerade as other cardiac disorders. The extended use of echocardiography may contribute to an erroneous diagnosis of hypertrophic cardiomyopathy, as both conditions show several features in common. This was the case with the patient reported below. A low QRS amplitude, an increased right ventricular wall thickness, thickened cardiac valves, and a pericardial effusion may, however, indicate amyloid infiltration. The diagnosis of systemic amyloidosis of immunocytic origin was subsequently established in our patient. A definitive diagnosis of amyloid heart disease requires endomyocardial biopsy, but it is suggested that typical noninvasive findings together with demonstration of amyloid in an organ other than the heart is sufficient for a reliable diagnosis. In addition, systemic manifestations may contribute to a correct diagnosis in generalized amyloidosis. Our patient had features consistent with the rare muscle pseudohypertrophy syndrome, which is associated with immunocytic amyloidosis.
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Abstract
Primary amyloidosis, systemic senile amyloidosis, isolated atrial amyloidosis, and transthyretin isoleucine 122 amyloidosis frequently involve the heart. Amyloid fibrils infiltrate the myocardium, impairing ventricular contraction and relaxation. The clinical manifestations of cardiac infiltration in these disorders are protean, though congestive heart failure and arrhythmias are most common. Treatment of cardiac amyloidosis is directed at the underlying cause and at relief of symptoms. Heart transplantation is not a viable treatment option for patients with primary amyloidosis; its role in the other amyloidoses has not been established. The prognosis of patients with cardiac amyloidosis varies and is largely determined by the underlying disorder responsible for amyloid infiltration.
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Affiliation(s)
- R E McCarthy
- Division of Cardiology, Johns Hopkins Hospital, Baltimore, MD 21205, USA
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Lubitz SA, Goldbarg SH, Mehta D. Sudden cardiac death in infiltrative cardiomyopathies: sarcoidosis, scleroderma, amyloidosis, hemachromatosis. Prog Cardiovasc Dis 2008; 51:58-73. [PMID: 18634918 DOI: 10.1016/j.pcad.2007.10.003] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Sarcoidosis, scleroderma, amyloidosis, and hemachromatosis are systemic infiltrative disorders that commonly affect the heart. Owing to their potential for diffuse organ involvement, these diseases may present with myriad clinical manifestations. Conduction system abnormalities are common, and each of these disorders has been associated with sudden cardiac death. In this review, we summarize the epidemiology, clinical features, diagnosis, and treatment of each of these entities. We place special emphasis on existing literature as it pertains to risk stratification and therapy aimed at the prevention of sudden cardiac death in these infiltrative cardiomyopathies.
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Affiliation(s)
- Steven A Lubitz
- Zena and Michael Wiener Cardiovascular Institute, Mount Sinai School of Medicine, NY, USA
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Cardiovascular magnetic resonance in clinically suspected cardiac amyloidosis: noninvasive imaging compared to endomyocardial biopsy. J Am Coll Cardiol 2008; 51:1022-30. [PMID: 18325442 DOI: 10.1016/j.jacc.2007.10.049] [Citation(s) in RCA: 347] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2007] [Revised: 09/24/2007] [Accepted: 10/31/2007] [Indexed: 12/19/2022]
Abstract
OBJECTIVES We sought to evaluate the diagnostic performance of cardiovascular magnetic resonance imaging (CMRI) for detection of cardiac amyloidosis compared with endomyocardial biopsy (EMB) in a clinical routine setting. BACKGROUND For the clinical workup of heart failure with restrictive filling, pattern cardiac amyloidosis is an important differential diagnosis that is difficult to verify with current noninvasive techniques, especially in the presence of myocardial hypertrophy. METHODS A total of 33 consecutive patients underwent both CMRI and EMB for workup of heart failure with restrictive filling pattern in combination with myocardial hypertrophy (n = 24) and/or clinical conditions often associated with cardiac amyloidosis (n = 18). RESULTS Cardiac amyloidosis was detected by EMB in 15 of the 33 patients. In patients with biopsy-proven cardiac amyloidosis, CMRI revealed a distinct pattern of late gadolinium enhancement, which was distributed over the entire subendocardial circumference, extending in various degrees into the neighboring myocardium. This pattern was found in 12 of the 15 patients diagnosed with cardiac amyloidosis by EMB, compared with only 1 individual in the group of 18 patients diagnosed with other myocardial diseases. Consequently, using this pattern as a diagnostic criterion, the sensitivity of CMRI for diagnosing cardiac amyloidosis was 80%, yielding a specificity of 94%. The positive predictive value was 92%, and the negative predictive value was 85%. CONCLUSIONS In patients with biopsy-proven cardiac amyloidosis, late gadolinium enhancement frequently occurs in a peculiar pattern. On the basis of the gold standard, EMB, noninvasive CMRI can be used to diagnose or rule out cardiac amyloidosis with good sensitivity and excellent specificity in a clinical routine setting.
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Kingsbury JS, Laue TM, Klimtchuk ES, Théberge R, Costello CE, Connors LH. The modulation of transthyretin tetramer stability by cysteine 10 adducts and the drug diflunisal. Direct analysis by fluorescence-detected analytical ultracentrifugation. J Biol Chem 2008; 283:11887-96. [PMID: 18326041 DOI: 10.1074/jbc.m709638200] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Transthyretin (TTR) is normally a stable plasma protein. However, in cases of familial TTR-related amyloidosis and senile systemic amyloidosis (SSA), TTR is deposited as amyloid fibrils, leading to organ dysfunction and possibly death. The mechanism by which TTR undergoes the transition from stable, soluble precursor to insoluble amyloid fibril and the factors that promote this process are largely undetermined. Most models involve the dissociation of the native TTR tetramer as the initial step. It is largely accepted that the TTR gene mutations associated with TTR-related amyloidosis lead to the expression of variant proteins that are intrinsically unstable and prone to aggregation. It has been suggested that amyloidogenicity may be conferred to wild-type TTR (the form deposited in SSA) by chemical modification of the lone cysteine residue (Cys(10)) through mixed disulfide bonds. S-Sulfonation and S-cysteinylation are prevalent TTR modifications physiologically, and studies have suggested their ability to modulate the structure of TTR under denaturing conditions. In the present study, we have used fluorescence-detected sedimentation velocity to determine the effect of S-sulfonate and S-cysteine on the quaternary structural stability of fluorophore-conjugated recombinant TTR under nondenaturing conditions. We determined that S-sulfonation stabilized TTR tetramer stability by a factor of 7, whereas S-cysteinylation enhanced dissociation by 2-fold with respect to the unmodified form. In addition, we report the direct observation of tetramer stabilization by the potential therapeutic compound diflunisal. Finally, as proof of concept, we report the sedimentation of TTR in serum and the qualitative assessment of the resulting data.
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Affiliation(s)
- Jonathan S Kingsbury
- Department of Biochemistry, Boston University School of Medicine, Boston, Massachusetts 02118, USA
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Sharma PP, Payvar S, Litovsky SH. Histomorphometric analysis of intramyocardial vessels in primary and senile amyloidosis: epicardium versus endocardium. Cardiovasc Pathol 2008; 17:65-71. [DOI: 10.1016/j.carpath.2007.05.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2007] [Revised: 05/23/2007] [Accepted: 05/31/2007] [Indexed: 10/22/2022] Open
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