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Teresi L, Trimarchi G, Liotta P, Restelli D, Licordari R, Carciotto G, Francesco C, Crea P, Dattilo G, Micari A, Emdin M, Berruezo A, Di Bella G. Electrocardiographic Patterns and Arrhythmias in Cardiac Amyloidosis: From Diagnosis to Therapeutic Management-A Narrative Review. J Clin Med 2024; 13:5588. [PMID: 39337075 PMCID: PMC11432666 DOI: 10.3390/jcm13185588] [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: 08/13/2024] [Revised: 09/06/2024] [Accepted: 09/12/2024] [Indexed: 09/30/2024] Open
Abstract
Electrophysiological aspects of cardiac amyloidosis (CA) are still poorly explored compared to other aspects of the disease. However, electrocardiogram (ECG) abnormalities play an important role in CA diagnosis and prognosis and the management of arrhythmias is a crucial part of CA treatment. Low voltages and a pseudonecrosis pattern with poor R-wave progression in precordial leads are especially common findings. These are useful for CA diagnosis and risk stratification, especially when combined with clinical or echocardiographic findings. Both ventricular and supraventricular arrhythmias are common in CA, especially in transthyretin amyloidosis (ATTR), and their prevalence is related to disease progression. Sustained and non-sustained ventricular tachycardias' prognostic role is still debated, and, to date, there is a lack of specific indications for implantable cardiac defibrillator (ICD). On the other hand, atrial fibrillation (AF) is the most common supraventricular arrhythmia with a prevalence of up to 88% of ATTR patients. Anticoagulation should be considered irrespective of CHADsVA score. Furthermore, even if AF seems to not be an independent prognostic factor in CA, its treatment for symptom control is still crucial. Finally, conduction disturbances and bradyarrhythmias are also common, requiring pacemaker implantation in up to 40% of patients.
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Affiliation(s)
- Lucio Teresi
- Department of Clinical and Experimental Medicine, University of Messina, 98100 Messina, Italy
- Heart Institute, Teknon Medical Centre, 08022 Barcelona, Spain
| | - Giancarlo Trimarchi
- Department of Clinical and Experimental Medicine, University of Messina, 98100 Messina, Italy
- Health Science Interdisciplinary Center, Scuola Superiore Sant’Anna, 56127 Pisa, Italy
| | - Paolo Liotta
- Department of Clinical and Experimental Medicine, University of Messina, 98100 Messina, Italy
| | - Davide Restelli
- Department of Clinical and Experimental Medicine, University of Messina, 98100 Messina, Italy
| | - Roberto Licordari
- Department of Clinical and Experimental Medicine, University of Messina, 98100 Messina, Italy
| | - Gabriele Carciotto
- Department of Clinical and Experimental Medicine, University of Messina, 98100 Messina, Italy
| | - Costa Francesco
- Department of Clinical and Experimental Medicine, University of Messina, 98100 Messina, Italy
- Departamento de Medicina UMA, Área del Corazón, Hospital Universitario Virgen de la Victoria, Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV), IBIMA Plataforma BIONAND, 29010 Malaga, Spain
| | - Pasquale Crea
- Department of Clinical and Experimental Medicine, University of Messina, 98100 Messina, Italy
| | - Giuseppe Dattilo
- Department of Clinical and Experimental Medicine, University of Messina, 98100 Messina, Italy
| | - Antonio Micari
- Department of Biomedical and Dental Sciences and Morphological and Functional Imaging, University of Messina, 98100 Messina, Italy
| | - Michele Emdin
- Health Science Interdisciplinary Center, Scuola Superiore Sant’Anna, 56127 Pisa, Italy
- Fondazione Toscana Gabriele Monasterio, 56124 Pisa, Italy
| | | | - Gianluca Di Bella
- Department of Clinical and Experimental Medicine, University of Messina, 98100 Messina, Italy
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2
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Compagnucci P, Dello Russo A, Gasperetti A, Schiavone M, Sehrawat O, Hasegawa K, Mohanty S, Liang JJ, Kapa S, La Fazia VM, Bogun F, Stevenson WG, Tondo C, Siontis KC, Tandri H, Santangeli P, Natale A, Casella M. Substrate Characterization and Outcomes of Ventricular Tachycardia Ablation in Amyloid Cardiomyopathy: A Multicenter Study. Circ Arrhythm Electrophysiol 2024; 17:e012788. [PMID: 39171384 DOI: 10.1161/circep.124.012788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 07/03/2024] [Indexed: 08/23/2024]
Abstract
BACKGROUND Sustained ventricular tachycardia (VT) in cardiac amyloidosis is uncommon, and the substrate and outcomes of catheter ablation are not defined. METHODS We included 22 consecutive patients (mean age, 68±10 years; male sex, 91%) with cardiac amyloidosis (ATTR [transthyretin], n=16; light chain, n=6) undergoing catheter ablation for VT/ventricular fibrillation (VF) between 2013 and 2023 in a retrospective, observational, international study. The primary efficacy outcome was recurrent VT/VF during follow-up, while the primary safety end point included major procedure-related adverse events. RESULTS The indication for ablation was drug-refractory VT in 17 patients (77%), and premature ventricular complex-initiated polymorphic VT/VF in 5 patients (23%). Catheter ablation was performed using endocardial (n=17.77%) or endo-epicardial approaches (n=5.23%). Complete endocardial electroanatomical voltage maps of the left and right ventricles were obtained in 17 (77%) and 10 (45%) patients, respectively. Each patient had evidence of low-voltage areas, most commonly involving the interventricular septum (n=16); late potentials were recorded in 16 patients (73%). A median of 1 (1-2) VT was inducible per patient; 12 of the 26 mappable VTs (46%) originated from the interventricular septum. Complete procedural success was achieved in 16 patients (73%), with 4 (18%) major procedure-related adverse events. After a median follow-up of 32 (14-42) months, sustained VT/VF recurrence was observed in 9 patients (41%); survival free from VT/VF recurrence was 56% (95% CI, 36%-86%) at 36-month follow-up, and most patients remained on antiarrhythmic drugs. A significant reduction in per patient implantable cardioverter defibrillator therapies was noted in the 6-month period after ablation (before: 6 [4-9] versus after: 0 [0-0]; P<0.001). In multivariable analysis, complete procedural success was associated with reduced risk of recurrent VT/VF (hazard ratio, 0.002; P=0.034). CONCLUSIONS Catheter ablation can achieve control of recurrent VT/VF in more than half of patients with cardiac amyloidosis, and the reduction in VT/VF burden post-ablation may be relevant for quality of life. Septal substrate and risk of procedure-related complications challenge successful management of patients with cardiac amyloidosis and VT/VF.
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Affiliation(s)
- Paolo Compagnucci
- Cardiology and Arrhythmology Clinic, University Hospital Azienda Ospedaliero-Universitaria delle Marche, Ancona, Italy (P.C., A.D.R., M.C.)
| | - Antonio Dello Russo
- Cardiology and Arrhythmology Clinic, University Hospital Azienda Ospedaliero-Universitaria delle Marche, Ancona, Italy (P.C., A.D.R., M.C.)
- Department of Biomedical Sciences and Public Health (A.D.R., A.G.), Marche Polytechnic University, Ancona, Italy
| | - Alessio Gasperetti
- Department of Biomedical Sciences and Public Health (A.D.R., A.G.), Marche Polytechnic University, Ancona, Italy
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD (A.G.)
| | - Marco Schiavone
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy (M.S., C.T.)
| | - Ojasav Sehrawat
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (O.S., S.K., K.C.S.)
| | - Kanae Hasegawa
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (K.H., W.G.S., H.T.)
| | - Sanghamitra Mohanty
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (S.M., V.M.L.F., A.N.)
| | - Jackson J Liang
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (J.J.L., F.B.)
| | - Suraj Kapa
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN (O.S., S.K., K.C.S.)
| | - Vincenzo Mirco La Fazia
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (S.M., V.M.L.F., A.N.)
| | - Frank Bogun
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (J.J.L., F.B.)
| | - William G Stevenson
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (K.H., W.G.S., H.T.)
| | - Claudio Tondo
- Department of Clinical Electrophysiology and Cardiac Pacing, Centro Cardiologico Monzino, Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy (M.S., C.T.)
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, Italy (C.T.)
| | | | - Harikrishna Tandri
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (K.H., W.G.S., H.T.)
| | | | - Andrea Natale
- Texas Cardiac Arrhythmia Institute, St. David's Medical Center, Austin (S.M., V.M.L.F., A.N.)
- Interventional Electrophysiology, Scripps Clinic, San Diego, CA (A.N.)
- Department of Internal Medicine, Metro Health Medical Center, Case Western Reserve University School of Medicine, Cleveland, OH (A.N.)
- Department of Biomedicine and Prevention, Division of Cardiology, University of Rome Tor Vergata, Italy (A.N.)
| | - Michela Casella
- Cardiology and Arrhythmology Clinic, University Hospital Azienda Ospedaliero-Universitaria delle Marche, Ancona, Italy (P.C., A.D.R., M.C.)
- Department of Clinical, Special and Dental Sciences (M.C.), Marche Polytechnic University, Ancona, Italy
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Sabzwari SRA, Tzou WS. Systemic Diseases and Heart Block. Rheum Dis Clin North Am 2024; 50:381-408. [PMID: 38942576 DOI: 10.1016/j.rdc.2024.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2024]
Abstract
Systemic diseases can cause heart block owing to the involvement of the myocardium and thereby the conduction system. Younger patients (<60) with heart block should be evaluated for an underlying systemic disease. These disorders are classified into infiltrative, rheumatologic, endocrine, and hereditary neuromuscular degenerative diseases. Cardiac amyloidosis owing to amyloid fibrils and cardiac sarcoidosis owing to noncaseating granulomas can infiltrate the conduction system leading to heart block. Accelerated atherosclerosis, vasculitis, myocarditis, and interstitial inflammation contribute to heart block in rheumatologic disorders. Myotonic, Becker, and Duchenne muscular dystrophies are neuromuscular diseases involving the myocardium skeletal muscles and can cause heart block.
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Affiliation(s)
- Syed Rafay A Sabzwari
- University of Colorado Anschutz Medical Campus, 12631 East 17th Avenue, Mail Stop B130, Aurora, CO 80045, USA
| | - Wendy S Tzou
- Cardiac Electrophysiology, University of Colorado Anschutz Medical Campus, 12401 E 17th Avenue, MS B-136, Aurora, CO 80045, USA.
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Bonvicini E, Preda A, Tognola C, Falco R, Gidiucci R, Leo G, Vargiu S, Varrenti M, Gigli L, Baroni M, Carbonaro M, Colombo G, Maloberti A, Giannattasio C, Mazzone P, Guarracini F. Arrhythmic Risk Stratification in Cardiac Amyloidosis: A Review of the Current Literature. J Cardiovasc Dev Dis 2024; 11:222. [PMID: 39057642 PMCID: PMC11277134 DOI: 10.3390/jcdd11070222] [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: 05/15/2024] [Revised: 07/10/2024] [Accepted: 07/12/2024] [Indexed: 07/28/2024] Open
Abstract
Cardiac amyloidosis is the most frequent infiltrative disease caused by the deposition of misfolded proteins in the cardiac tissue, leading to heart failure, brady- and tachyarrhythmia and death. Conduction disorders, atrial fibrillation (AF) and ventricular arrhythmia (VA) significantly impact patient outcomes and demand recognition. However, several issues remain unresolved regarding early diagnosis and optimal management. Extreme bradycardia is the most common cause of arrhythmic death, while fast and sustained VAs can be found even in the early phases of the disease. Risk stratification and the prevention of sudden cardiac death are therefore to be considered in these patients, although the time for defibrillator implantation is still a subject of debate. Moreover, atrial impairment due to amyloid fibrils is associated with an increased risk of AF resistant to antiarrhythmic therapy, as well as recurrent thromboembolic events despite adequate anticoagulation. In the last few years, the aging of the population and progressive improvements in imaging methods have led to increases in the diagnosis of cardiac amyloidosis. Novel therapies have been developed to improve patients' functional status, quality of life and mortality, without data regarding their effect on arrhythmia prevention. In this review, we consider the latest evidence regarding the arrhythmic risk stratification of cardiac amyloidosis, as well as the available therapeutic strategies.
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Affiliation(s)
| | - Alberto Preda
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (S.V.)
| | - Chiara Tognola
- Clinical Cardiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy; (C.T.); (A.M.)
| | - Raffaele Falco
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (S.V.)
| | - Roberto Gidiucci
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (S.V.)
| | - Giulio Leo
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (S.V.)
| | - Sara Vargiu
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (S.V.)
| | - Marisa Varrenti
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (S.V.)
| | - Lorenzo Gigli
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (S.V.)
| | - Matteo Baroni
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (S.V.)
| | - Marco Carbonaro
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (S.V.)
| | - Giulia Colombo
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (S.V.)
| | - Alessandro Maloberti
- Clinical Cardiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy; (C.T.); (A.M.)
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
| | - Cristina Giannattasio
- Clinical Cardiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy; (C.T.); (A.M.)
- School of Medicine and Surgery, University of Milano-Bicocca, 20126 Milan, Italy
| | - Patrizio Mazzone
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (S.V.)
| | - Fabrizio Guarracini
- Electrophysiology Unit, De Gasperis Cardio Center, Niguarda Hospital, 20162 Milan, Italy (S.V.)
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5
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Mazza A, Bendini MG, Leggio M, Imberti JF, Valsecchi S, Boriani G. Clinical significance and prognostic value of right bundle branch block in permanent pacemaker patients. J Cardiovasc Med (Hagerstown) 2024; 25:551-558. [PMID: 38809231 DOI: 10.2459/jcm.0000000000001641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/30/2024]
Abstract
AIMS In patients undergoing pacemaker implantation with no prior history of heart failure (HF), the presence of left bundle branch block (LBBB) has been identified as an independent predictor of HF-related death or hospitalization, while the prognostic significance of right bundle branch block (RBBB) remains uncertain. We aimed to assess the long-term risk of all-cause mortality in patients with a standard indication for permanent pacing and normal or moderately depressed left ventricular function when RBBB is detected at the time of implantation. METHODS We retrospectively enrolled 1348 consecutive patients who had undergone single- or dual-chamber pacemaker implantation at the study center, from January 1990 to December 2022. Patients with a left ventricular ejection fraction ≤35% or a prior diagnosis of HF were excluded. RESULTS The baseline 12-lead electrocardiogram revealed an RBBB in 241 (18%) and an LBBB in 98 (7%) patients. During a median follow-up of 65 [25th-75th percentile: 32-117] months, 704 (52%) patients died. The combined endpoint of cardiovascular death or HF hospitalization was reached by 173 (13%) patients. On multivariate analysis, RBBB was confirmed as an independent predictor of death [hazard ratio, 1.33; 95% confidence interval (CI), 1.09-1.63; P = 0.005]. However, when considering the combined endpoint of cardiovascular death and HF hospitalization, this endpoint was independently associated with LBBB (hazard ratio, 2.13; 95% CI, 1.38-3.29; P < 0.001), but not with RBBB. CONCLUSION In patients with standard pacemaker indications and normal or moderately depressed left ventricular function, the presence of basal RBBB was an independent predictor of mortality. However, it was not associated with the combined endpoint of cardiovascular death and HF hospitalization.
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Affiliation(s)
- Andrea Mazza
- Cardiology Division, S. Maria della Stella Hospital, Orvieto
| | | | - Massimo Leggio
- Clinica Salus Infirmorum, S. Filippo Neri Hospital, Rome
| | - Jacopo F Imberti
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia
| | | | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena
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6
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Wang J, Li J, Zhong L. Current status and prospect of anti-amyloid fibril therapy in AL amyloidosis. Blood Rev 2024; 66:101207. [PMID: 38692939 DOI: 10.1016/j.blre.2024.101207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 04/11/2024] [Accepted: 04/14/2024] [Indexed: 05/03/2024]
Abstract
Amyloid light-chain (AL) amyloidosis is a rare hematological disease that produces abnormal monoclonal immunoglobulin light chains to form amyloid fibrils that are deposited in tissues, resulting in organ damage and dysfunction. Advanced AL amyloidosis has a very poor prognosis with a high risk of early mortality. The combination of anti-plasma cell therapy and amyloid fibrils clearance is the optimal treatment strategy, which takes into account both symptoms and root causes. However, research on anti-amyloid fibrils lags far behind research on anti-plasma cells, and there is currently no approved treatment that could clear amyloid fibrils. Nevertheless, anti-amyloid fibril therapies are being actively investigated recently and have shown potential in clinical trials. In this review, we aim to outline the preclinical work and clinical efficacy of fibril-directed therapies for AL amyloidosis.
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Affiliation(s)
- Jinghua Wang
- Department of Hematology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China
| | - Jian Li
- Department of Hematology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
| | - Liye Zhong
- Department of Hematology, Guangdong Provincial People's Hospital (Guangdong Academy of Medical Sciences), Southern Medical University, Guangzhou, China.
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7
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Pozzan M, Indennidate C, Varrà GG, Sinagra G, Merlo M, Pagura L. Amyloidosis and Amyloidogenesis: One Name, Many Diseases. Heart Fail Clin 2024; 20:249-260. [PMID: 38844296 DOI: 10.1016/j.hfc.2024.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/11/2024]
Abstract
Amyloidosis is a heterogenous group of disorders, caused by the deposition of insoluble fibrils derived from misfolded proteins in the extracellular space of various organs. These proteins have an unstable structure that causes them to misfold, aggregate, and deposit as amyloid fibrils with the pathognomonic histologic property of green birefringence when viewed under cross-polarized light after staining with Congo red. Amyloid fibrils are insoluble and degradation-resistant; resistance to catabolism results in progressive tissue amyloid accumulation. The outcome of this process is organ disfunction independently from the type of deposited protein, however there can be organ that are specifically targeted from certain proteins.
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Affiliation(s)
- Marco Pozzan
- Cardiovascular Department, Center for Diagnosis and Treatment of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Via P. Valdoni 7, Trieste 34100, Italy
| | - Carla Indennidate
- Cardiovascular Department, Center for Diagnosis and Treatment of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Via P. Valdoni 7, Trieste 34100, Italy
| | - Guerino Giuseppe Varrà
- Cardiovascular Department, Center for Diagnosis and Treatment of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Via P. Valdoni 7, Trieste 34100, Italy
| | - Gianfranco Sinagra
- Cardiovascular Department, Center for Diagnosis and Treatment of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Via P. Valdoni 7, Trieste 34100, Italy
| | - Marco Merlo
- Cardiovascular Department, Center for Diagnosis and Treatment of Cardiomyopathies, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Low Prevalence and Complex Diseases of the Heart-ERN GUARD-Heart, Via P. Valdoni 7, Trieste 34100, Italy; European Reference Network for Rare Low Prevalence and Complex Diseases of the Heart-ERN GUARD Heart Via P. Valdoni 7 Trieste 34100, Italy.
| | - Linda Pagura
- Division of Cardiac Surgery, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Via P. Valdoni 7, Trieste 34100, Italy
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8
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Holcman K, Ząbek A, Boczar K, Podolec P, Kostkiewicz M. Management of Arrhythmias and Conduction Disorders in Amyloid Cardiomyopathy. J Clin Med 2024; 13:3088. [PMID: 38892799 PMCID: PMC11172576 DOI: 10.3390/jcm13113088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2024] [Revised: 05/19/2024] [Accepted: 05/22/2024] [Indexed: 06/21/2024] Open
Abstract
Cardiac amyloidosis, a condition characterized by abnormal protein deposition in the heart, leads to restrictive cardiomyopathy and is notably associated with an increased risk of arrhythmias and conduction disorders. This article reviews the current understanding and management strategies for these cardiac complications, with a focus on recent advancements and clinical challenges. The prevalence and impact of atrial arrhythmias, particularly atrial fibrillation, are examined, along with considerations for stroke risk and anticoagulation therapy. The article also addresses the complexities of managing rate and rhythm control, outlining the utility and limitations of pharmacological agents and interventions such as catheter ablation. Furthermore, it reviews the challenges in the treatment of ventricular arrhythmias, including the contentious use of implantable cardioverter-defibrillators for primary and secondary prevention. Individualized approaches, considering the unique characteristics of cardiac amyloidosis, are paramount. Continuous research and clinical exploration are essential to refine treatment strategies and improve outcomes in this challenging patient population.
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Affiliation(s)
- Katarzyna Holcman
- Department of Nuclear Medicine, John Paul II Hospital, 31-202 Krakow, Poland;
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital, 31-202 Krakow, Poland;
| | - Andrzej Ząbek
- Department of Electrocardiology, Jagiellonian University Medical College, John Paul II Hospital, 31-202 Krakow, Poland; (A.Z.); (K.B.)
| | - Krzysztof Boczar
- Department of Electrocardiology, Jagiellonian University Medical College, John Paul II Hospital, 31-202 Krakow, Poland; (A.Z.); (K.B.)
| | - Piotr Podolec
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital, 31-202 Krakow, Poland;
| | - Magdalena Kostkiewicz
- Department of Nuclear Medicine, John Paul II Hospital, 31-202 Krakow, Poland;
- Department of Cardiac and Vascular Diseases, Jagiellonian University Medical College, John Paul II Hospital, 31-202 Krakow, Poland;
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9
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Martini N, Sinigiani G, De Michieli L, Mussinelli R, Perazzolo Marra M, Iliceto S, Zorzi A, Perlini S, Corrado D, Cipriani A. Electrocardiographic features and rhythm disorders in cardiac amyloidosis. Trends Cardiovasc Med 2024; 34:257-264. [PMID: 36841466 DOI: 10.1016/j.tcm.2023.02.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 02/16/2023] [Accepted: 02/18/2023] [Indexed: 02/27/2023]
Abstract
Cardiac amyloidosis (CA) is an infiltrative cardiomyopathy caused by extracellular deposition of amyloid fibrils, mainly derived from transthyretin, either wild-type or hereditary variants, or immunoglobulin light chains misfolding. It is characterized by an increased left ventricular (LV) mass and diastolic dysfunction, which can lead to heart failure with preserved ejection fraction and/or conduction disturbances. The diagnosis is based on invasive pathology demonstration of amyloid deposits, or non-invasive criteria using advanced cardiovascular imaging techniques. Nevertheless, 12-lead electrocardiogram (ECG) remains of crucial importance in the assessment of patients with CA, since they can manifest peculiar features such as low QRS voltages, in discordance with the LV hypertrophy, but also pseudo-infarction patterns, sinus node dysfunction, atrioventricular blocks, premature supraventricular and ventricular beats, which support the presence of a myocardial disease. Great awareness of these common ECG characteristics of CA is needed to increase diagnostic performance and improve patient's outcome. In the present review, we discuss the current role of the ECG in the diagnosis and management of CA, focusing on the most common ECG abnormalities and rhythm disorders.
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Affiliation(s)
- Nicolò Martini
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Giulio Sinigiani
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Laura De Michieli
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Roberta Mussinelli
- Amyloidosis Research and Treatment Center, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Martina Perazzolo Marra
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Sabino Iliceto
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Alessandro Zorzi
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Stefano Perlini
- Amyloidosis Research and Treatment Center, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy; Emergency Medicine, Vascular and Metabolic Disease Unit, Department of Internal Medicine, IRCCS Policlinico San Matteo Foundation, University of Pavia, Pavia, Italy
| | - Domenico Corrado
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy
| | - Alberto Cipriani
- Department of Cardio-Thoraco-Vascular Sciences and Public Health, University of Padua, Via Giustiniani, 2, Padua 35128, Italy.
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10
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Chen Z, Shi A, Dong H, Laptseva N, Chen F, Yang J, Guo X, Duru F, Chen K, Chen L. Prognostic implications of premature ventricular contractions and non-sustained ventricular tachycardia in light-chain cardiac amyloidosis. Europace 2024; 26:euae063. [PMID: 38466042 DOI: 10.1093/europace/euae063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 03/06/2024] [Indexed: 03/12/2024] Open
Abstract
AIMS Premature ventricular contractions (PVC) and non-sustained ventricular tachycardia (NSVT) are commonly observed in light chain cardiac amyloidosis (AL-CA), but their association with prognosis is still unclear. We aimed to evaluate the prognostic value of PVCs and NSVT in patients with moderate-to-advanced AL-CA. METHODS AND RESULTS We retrospectively included patients with AL-CA at modified 2004 Mayo stages II-IIIb between February 2014 and December 2020. Twenty-four-hour Holter recordings were assessed on admission. The outcomes included (i) new onset of adverse ventricular arrhythmia (VA) or sudden cardiac death (SCD) and (ii) cardiac death during follow-up. Of the 143 patients studied (60.41 ± 11.06 years, male 64.34%), 132 (92.31%) had presence of PVC, and 50 (34.97%) had NSVT on Holter. Twelve (8.4%) patients died in hospital and 131 patients were followed up (median 24.4 months), among whom 71 patients had cardiac death, and 15 underwent adverse VA/SCD. NSVT [hazard ratio (HR): 13.57, 95% confidence interval (CI): 3.06-60.18, P < 0.001], log-transformed PVC counts (HR: 1.46, 95%CI: 1.15-1.86, P = 0.002) and PVC burden (HR: 1.43 95%CI:1.14-1.80, P = 0.002) were predictive of new onset of adverse VA/SCD. The highest tertile of PVC counts (HR: 2.33, 95%CI: 1.27-4.28, P = 0.006) and PVC burden (HR: 2.58, 95%CI: 1.42-4.69, P = 0.002), rather than NSVT (HR: 1.16, 95%CI: 0.67-1.98, P = 0.603), was associated with cardiac death. Higher PVC counts/burden provided incremental value on modified 2004 Mayo stage in predicting cardiac death, with C index increasing from 0.681 to 0.712 and 0.717, respectively (P values <0.05). CONCLUSION PVC count, burden, and NSVT significantly correlated with adverse VA/SCD during follow-up in patients with AL-CA. Higher PVC counts/burdens added incremental value for predicting cardiac death.
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Affiliation(s)
- Zhongli Chen
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No. 167 North Lishi Road, Xicheng District, Beijing 100037, China
- Cardiac Arrhythmia Center, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No. 167 North Lishi Road, Xicheng District, Beijing 10037, China
| | - Anteng Shi
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No. 167 North Lishi Road, Xicheng District, Beijing 100037, China
| | - Hongbin Dong
- Department of Radiology, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No. 167 North Lishi Road, Xicheng District, Beijing 10037, China
| | - Natallia Laptseva
- Division of Heart Failure, Department of Cardiology, University Heart Center, Rämistrasse 100, Zurich CH-8091, Switzerland
| | - Feng Chen
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No. 167 North Lishi Road, Xicheng District, Beijing 100037, China
- Cardiac Arrhythmia Center, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No. 167 North Lishi Road, Xicheng District, Beijing 10037, China
| | - Jiandu Yang
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No. 167 North Lishi Road, Xicheng District, Beijing 100037, China
- Cardiac Arrhythmia Center, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No. 167 North Lishi Road, Xicheng District, Beijing 10037, China
| | - Xiaogang Guo
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No. 167 North Lishi Road, Xicheng District, Beijing 100037, China
- Cardiac Arrhythmia Center, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No. 167 North Lishi Road, Xicheng District, Beijing 10037, China
| | - Firat Duru
- Center for Translational and Experimental Cardiology, University of Zurich, Rämistrasse 100, Zurich CH-8091, Switzerland
- Division of Cardiac Arrhythmias, Department of Cardiology, University Heart Center, Rämistrasse 100, Zurich CH-8091, Switzerland
| | - Keping Chen
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No. 167 North Lishi Road, Xicheng District, Beijing 100037, China
- Cardiac Arrhythmia Center, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No. 167 North Lishi Road, Xicheng District, Beijing 10037, China
| | - Liang Chen
- State Key Laboratory of Cardiovascular Disease, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Fuwai Hospital, No. 167 North Lishi Road, Xicheng District, Beijing 100037, China
- Center for Translational and Experimental Cardiology, University of Zurich, Rämistrasse 100, Zurich CH-8091, Switzerland
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11
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Nery PB, Birnie DH. Prognostic Information From Endocardial Voltage Mapping at the Time of Endomyocardial Biopsy for the Diagnosis of Cardiac Amyloidosis. Can J Cardiol 2024; 40:385-387. [PMID: 38159642 DOI: 10.1016/j.cjca.2023.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 12/11/2023] [Accepted: 12/18/2023] [Indexed: 01/03/2024] Open
Affiliation(s)
- Pablo B Nery
- Arrhythmia Service, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada.
| | - David H Birnie
- Arrhythmia Service, Division of Cardiology, Department of Medicine, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
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12
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Saturi G, De Frutos F, Sguazzotti M, Gonzalez-Lopez E, Nardi E, Domínguez F, Ponziani A, Cabrera E, Caponetti AG, Lozano S, Massa P, Cobo-Marcos M, Accietto A, Castro-Urda V, Giovannetti A, Toquero J, Gagliardi C, Gómez-Bueno M, Rios-Tamayo R, Biagini E, Segovia J, Galiè N, García-Pavía P, Longhi S. Predictors and outcomes of pacemaker implantation in patients with cardiac amyloidosis. Heart 2023; 110:40-48. [PMID: 37414523 DOI: 10.1136/heartjnl-2022-322315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Accepted: 05/26/2023] [Indexed: 07/08/2023] Open
Abstract
OBJECTIVE We sought to investigate prevalence, incidence and prognostic implications of permanent pacemaker (PPM) implantation in patients with cardiac amyloidosis (CA), thereby identifying the predictors of time to PPM implantation. METHODS Seven hundred eighty-seven patients with CA (602 men, median age 74 years, 571 transthyretin amyloidosis (ATTR), 216 light-chain amyloidosis (AL)) evaluated at two European referral centres were retrospectively included. Clinical, laboratory and instrumental data were analysed. The associations between PPM implantation and mortality, heart failure (HF) or a composite endpoint of mortality, cardiac transplantation and HF were analysed. RESULTS 81 (10.3%) patients had a PPM before initial evaluation. Over a median follow-up time of 21.7 months (IQR 9.6-45.2), 81 (10.3%) additional patients (18 with AL (22.2%) and 63 with ATTR (77.8%)) underwent PPM implantation with a median time to implantation of 15.6 months (IQR 4.2-40), complete atrioventricular block was the most common indication (49.4%). Independent predictors of PPM implantation were QRS duration (HR 1.03, 95% CI 1.02 to 1.03, p<0.001) and interventricular septum (IVS) thickness (HR 1.1, 95% CI 1.03 to 1.17, p=0.003). The model to estimate the probability of PPM at 12 months and containing both factors showed a C-statistic of 0.71 and a calibration of slope of 0.98. CONCLUSIONS Conduction system disease requiring PPM is a common complication in CA that affects up to 20.6% of patients. QRS duration and IVS thickness are independently associated with PPM implantation. A PPM implantation at 12 months model was devised and validated to identify patients with CA at higher risk of requiring a PPM and who require closer follow-up.
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Affiliation(s)
- Giulia Saturi
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Fernando De Frutos
- Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain
| | - Maurizio Sguazzotti
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Esther Gonzalez-Lopez
- Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain
| | - Elena Nardi
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Fernando Domínguez
- Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain
| | - Alberto Ponziani
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Eva Cabrera
- Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain
| | - Angelo Giuseppe Caponetti
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Sara Lozano
- Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain
| | - Paolo Massa
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Marta Cobo-Marcos
- Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain
| | - Antonella Accietto
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Victor Castro-Urda
- Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain
| | - Alessandro Giovannetti
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Jorge Toquero
- Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain
| | - Christian Gagliardi
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Manuel Gómez-Bueno
- Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain
| | - Rafael Rios-Tamayo
- Department of Hematology, Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, Madrid, Spain
| | - Elena Biagini
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Javier Segovia
- Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain
| | - Nazzareno Galiè
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Bologna, Italy
| | - Pablo García-Pavía
- Department of Cardiology, Hospital Universitario Puerta de Hierro, IDIPHISA, CIBERCV, Madrid, Spain
- Universidad Francisco de Vitoria, Pozuelo de Alarcon, Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
| | - Simone Longhi
- Cardiology Unit, Cardiac Thoracic and Vascular Department, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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13
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Bukhari S, Kasi A, Khan B. Bradyarrhythmias in Cardiac Amyloidosis and Role of Pacemaker. Curr Probl Cardiol 2023; 48:101912. [PMID: 37392977 DOI: 10.1016/j.cpcardiol.2023.101912] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Accepted: 06/27/2023] [Indexed: 07/03/2023]
Abstract
Cardiac amyloidosis (CA) is an underdiagnosed disease that is caused by deposition of misfolded transthyretin (ATTR) or immunoglobulin light chain (AL) fibrils in the myocardium. Bradyarrhythmias are commonly seen in CA, due to disruption of conducting system by amyloid fibrils. Atrioventricular conduction defect is more common than sinus node dysfunction. Bradyarrhythmias are most prevalent in wtATTR, followed by hATTR and AL. Pacemaker implantation, when indicated, can help provide symptomatic relief but does not confer mortality benefit. Progression of conduction system disease is common and often leads to increased right ventricular pacing burden with time. Therefore, cardiac resynchronizing therapy (biventricular therapy) is often considered as a better and safer option in these patients. Finally, the role of prophylactic pacemaker implantation is controversial, and current guidelines do not recommend prophylactic pacemaker insertion in CA patients.
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Affiliation(s)
- Syed Bukhari
- Department of Medicine, Temple University Hospital, Philadelphia, PA.
| | - Amail Kasi
- Department of Internal Medicine, National Hospital Quetta, Balochistan, Pakistan
| | - Bilal Khan
- Department of Medicine, Temple University Hospital-Jeanes Campus, Philadelphia, PA
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14
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Al-Sadawi M, Henriques MD, Gier C, Tao M, Almasry I, Singh A, Fan R, Rashba E. Effect of Defibrillator on All-Cause Mortality in Patients With Cardiac Amyloidosis. JACC. ADVANCES 2023; 2:100561. [PMID: 38939490 PMCID: PMC11198648 DOI: 10.1016/j.jacadv.2023.100561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/29/2024]
Affiliation(s)
| | | | | | | | | | | | | | - Eric Rashba
- Stony Brook Heart Rhythm Center, Stony Brook Medicine, 101 Nicolls Road, Stony Brook, New York 11794, USA
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15
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Briasoulis A, Kourek C, Papamichail A, Loritis K, Bampatsias D, Repasos E, Xanthopoulos A, Tsougos E, Paraskevaidis I. Arrhythmias in Patients with Cardiac Amyloidosis: A Comprehensive Review on Clinical Management and Devices. J Cardiovasc Dev Dis 2023; 10:337. [PMID: 37623350 PMCID: PMC10455774 DOI: 10.3390/jcdd10080337] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 08/01/2023] [Accepted: 08/03/2023] [Indexed: 08/26/2023] Open
Abstract
Cardiac amyloidosis (CA) is a rare but potentially life-threatening disease in which misfolded proteins accumulate in the cardiac wall tissue. Heart rhythm disorders in CA, including supraventricular arrhythmias, conduction system disturbances, or ventricular arrhythmias, play a major role in CA morbidity and mortality, and thus require supplementary management. Among them, AF is the most frequent arrhythmia during CA hospitalizations and is associated with significantly higher mortality, while ventricular arrhythmias are also common and are usually associated with poor prognosis. Early diagnosis of potential arrythmias could be performed through ECG, Holter monitoring, and/or electrophysiology study. Clinical management of these patients is quite significant, and it usually includes initiation of amiodarone and/or digoxin in patients with AF, potential electrical cardioversion, or ablation in specific patients with indication, as well as initiation of anticoagulants in all patients, independent of AF and CHADS-VASc score, for potential intracardiac thrombus. Moreover, identification of patients with conduction disorders that could benefit from prophylactic pacemaker implantation and/or CRT as well as identification of patients with life-threatening ventricular arrythmias that could benefit from ICD could both increase the survival rates of these patients and improve their quality of life.
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Affiliation(s)
- Alexandros Briasoulis
- Medical School of Athens, National and Kapodistrian University of Athens, 15772 Athens, Greece; (C.K.); (A.P.); (K.L.); (D.B.); (E.R.); (I.P.)
| | - Christos Kourek
- Medical School of Athens, National and Kapodistrian University of Athens, 15772 Athens, Greece; (C.K.); (A.P.); (K.L.); (D.B.); (E.R.); (I.P.)
| | - Adamantia Papamichail
- Medical School of Athens, National and Kapodistrian University of Athens, 15772 Athens, Greece; (C.K.); (A.P.); (K.L.); (D.B.); (E.R.); (I.P.)
| | - Konstantinos Loritis
- Medical School of Athens, National and Kapodistrian University of Athens, 15772 Athens, Greece; (C.K.); (A.P.); (K.L.); (D.B.); (E.R.); (I.P.)
| | - Dimitrios Bampatsias
- Medical School of Athens, National and Kapodistrian University of Athens, 15772 Athens, Greece; (C.K.); (A.P.); (K.L.); (D.B.); (E.R.); (I.P.)
| | - Evangelos Repasos
- Medical School of Athens, National and Kapodistrian University of Athens, 15772 Athens, Greece; (C.K.); (A.P.); (K.L.); (D.B.); (E.R.); (I.P.)
| | - Andrew Xanthopoulos
- Department of Cardiology, University Hospital of Larissa, 41110 Larissa, Greece;
| | - Elias Tsougos
- Department of Cardiology, Hygeia Hospital, 15123 Athens, Greece;
| | - Ioannis Paraskevaidis
- Medical School of Athens, National and Kapodistrian University of Athens, 15772 Athens, Greece; (C.K.); (A.P.); (K.L.); (D.B.); (E.R.); (I.P.)
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16
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Sabzwari SRA, Tzou WS. Systemic Diseases and Heart Block. Cardiol Clin 2023; 41:429-448. [PMID: 37321693 DOI: 10.1016/j.ccl.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
Systemic diseases can cause heart block owing to the involvement of the myocardium and thereby the conduction system. Younger patients (<60) with heart block should be evaluated for an underlying systemic disease. These disorders are classified into infiltrative, rheumatologic, endocrine, and hereditary neuromuscular degenerative diseases. Cardiac amyloidosis owing to amyloid fibrils and cardiac sarcoidosis owing to noncaseating granulomas can infiltrate the conduction system leading to heart block. Accelerated atherosclerosis, vasculitis, myocarditis, and interstitial inflammation contribute to heart block in rheumatologic disorders. Myotonic, Becker, and Duchenne muscular dystrophies are neuromuscular diseases involving the myocardium skeletal muscles and can cause heart block.
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Affiliation(s)
- Syed Rafay A Sabzwari
- University of Colorado Anschutz Medical Campus, 12631 East 17th Avenue, Mail Stop B130, Aurora, CO 80045, USA
| | - Wendy S Tzou
- Cardiac Electrophysiology, University of Colorado Anschutz Medical Campus, 12401 E 17th Avenue, MS B-136, Aurora, CO 80045, USA.
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17
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Duve RJ, Moga TG, Yang K, Mahl TC, Dove E. Hepatic Amyloidosis With Multiorgan Involvement. ACG Case Rep J 2023; 10:e00999. [PMID: 37091204 PMCID: PMC10115552 DOI: 10.14309/crj.0000000000000999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 02/03/2023] [Indexed: 04/25/2023] Open
Abstract
Amyloidosis is a diverse entity that poses both diagnostic and treatment challenges. Whether systemic or local, amyloidosis has varied manifestations including occasional hepatic involvement. Hepatic amyloidosis, although rare, should be on the differential for those with unexplained hepatomegaly, cholestasis, alkaline phosphatase elevations, other associated organomegaly, and those with certain epidemiologic risks. In this study, we report a case of a man with systemic amyloid light chain amyloidosis with multiorgan involvement, acute liver injury, cholestasis, nephrotic syndrome, cardiomegaly, and bleeding diathesis.
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Affiliation(s)
- Robert J. Duve
- Department of Internal Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY
| | - Tiberiu G. Moga
- Division of Gastroenterology, Hepatology, and Nutrition, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY
| | - Kevin Yang
- Department of Internal Medicine, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY
| | - Thomas C. Mahl
- Division of Gastroenterology, Hepatology, and Nutrition, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY
| | - Eric Dove
- Department of Pathology and Anatomical Sciences, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY
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18
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Laptseva N, Rossi VA, Sudano I, Schwotzer R, Ruschitzka F, Flammer AJ, Duru F. Arrhythmic Manifestations of Cardiac Amyloidosis: Challenges in Risk Stratification and Clinical Management. J Clin Med 2023; 12:jcm12072581. [PMID: 37048664 PMCID: PMC10095126 DOI: 10.3390/jcm12072581] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/23/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023] Open
Abstract
Amylodiosis is a systemic disease characterized by extracellular deposits of insoluble amyloid in various tissues and organs. Cardiac amyloidosis is a frequent feature of the disease, causing a progressive, restrictive type of cardiomyopathy, and is associated with adverse clinical outcomes and increased mortality. The typical clinical presentation in patients with cardiac amyloidosis is heart failure (HF) with preserved ejection fraction. Most patients present with typical symptoms and signs of HF, such as exertional dyspnea, pretibial edema, pleural effusions and angina pectoris due to microcirculatory dysfunction. However, patients may also frequently encounter various arrhythmias, such as atrioventricular nodal block, atrial fibrillation and ventricular tachyarrhythmias. The management of arrhythmias in cardiac amyloidosis patients with drugs and devices is often a clinical challenge. Moreover, predictors of life-threatening arrhythmic events are not well defined. This review intends to give a deepened insight into the arrhythmic features of cardiac amyloidosis by discussing the pathogenesis of these arrhythmias, addressing the challenges in risk stratification and strategies for management in these patients.
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19
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Kittleson MM, Ruberg FL, Ambardekar AV, Brannagan TH, Cheng RK, Clarke JO, Dember LM, Frantz JG, Hershberger RE, Maurer MS, Nativi-Nicolau J, Sanchorawala V, Sheikh FH. 2023 ACC Expert Consensus Decision Pathway on Comprehensive Multidisciplinary Care for the Patient With Cardiac Amyloidosis: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2023; 81:1076-1126. [PMID: 36697326 DOI: 10.1016/j.jacc.2022.11.022] [Citation(s) in RCA: 107] [Impact Index Per Article: 107.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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20
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Bukhari S, Khan B. Prevalence of ventricular arrhythmias and role of implantable cardioverter-defibrillator in cardiac amyloidosis. J Cardiol 2023; 81:429-433. [PMID: 36894119 DOI: 10.1016/j.jjcc.2023.02.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Revised: 02/27/2023] [Accepted: 02/28/2023] [Indexed: 03/09/2023]
Abstract
Cardiac amyloidosis is an underdiagnosed disease that is caused by myocardial deposition of misfolded light chain (AL) or transthyretin (ATTR) amyloid fibrils, leading to restrictive cardiomyopathy and eventually death if untreated. Ventricular arrhythmias are common in cardiac amyloidosis, and the prevalence is higher in AL than ATTR. There are multiple suspected pathogenic mechanisms for ventricular arrhythmia including activation of inflammatory cascade from direct amyloid deposition, and electro-mechanical as well as autonomic dysfunction due to systemic amyloid deposition. Cardiac amyloidosis is associated with an increased risk of sudden cardiac death, and the risk is higher in AL than ATTR. Finally, the role of implantable cardioverter-defibrillators in cardiac amyloidosis is controversial, and while successful termination of life-threatening ventricular arrhythmias has been reported in few studies, there has been no evidence of improvement in outcomes when used for primary prevention in patients with cardiac amyloidosis.
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Affiliation(s)
- Syed Bukhari
- Department of Medicine, Temple University Hospital-Jeanes Campus, Philadelphia, PA, USA.
| | - Bilal Khan
- Department of Medicine, Temple University Hospital-Jeanes Campus, Philadelphia, PA, USA
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21
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Imdad U. Amyloidosis of the Heart: A Comprehensive Review. Cureus 2023; 15:e35264. [PMID: 36968873 PMCID: PMC10035605 DOI: 10.7759/cureus.35264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/21/2023] [Indexed: 02/25/2023] Open
Abstract
Cardiac amyloidosis is a progressive, infiltrative cardiomyopathy, whose types are based on various infiltrating amyloids, namely, light chains in primary amyloidosis, mutated transthyretin proteins in hereditary amyloidosis, and wild-type transthyretin proteins in senile amyloidosis. While cardiac amyloidosis has a non-specific presentation, the type-specific presentations may provide some clues to the diagnosis. While tissue biopsy remains the gold standard, other newer non-invasive methods can aid in the diagnostic approach for suspected cardiac amyloidosis. Various medications used to treat heart failure may lead to adverse outcomes in patients with cardiac amyloidosis. More research is needed to understand the adequate management and treatment of cardiac amyloidosis.
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Pour-Ghaz I, Bath A, Kayali S, Alkhatib D, Yedlapati N, Rhea I, Khouzam RN, Jefferies JL, Nayyar M. A Review of Cardiac amyloidosis: Presentation, Diagnosis, and Treatment. Curr Probl Cardiol 2022; 47:101366. [PMID: 35995246 DOI: 10.1016/j.cpcardiol.2022.101366] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Accepted: 08/16/2022] [Indexed: 11/30/2022]
Abstract
Amyloidosis is a group of disorders that can affect almost any organ due to the misfolding of proteins with their subsequent deposition in various tissues, leading to various disease manifestations based on the location. When the heart is involved, amyloidosis can manifest with a multitude of presentations such as heart failure, arrhythmias, orthostatic hypotension, syncope, and pre-syncope. Diagnosis of cardiac amyloidosis can be difficult due to the non-specific nature of symptoms and the relative rarity of the disease. Amyloidosis can remain undiagnosed for years, leading to its high morbidity and mortality due to this delay in diagnosis. Newer imaging modalities, such as cardiac magnetic resonance imaging, advanced echocardiography, and biomarkers, make a timely cardiac amyloidosis diagnosis more feasible. Many treatment options are available, which have provided new hope for this patient population. This manuscript will review the pathology, diagnosis, and treatment options available for cardiac amyloidosis and provide a comprehensive overview of this complicated disease process.
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Affiliation(s)
- Issa Pour-Ghaz
- Department of Internal Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, TN.
| | - Anandbir Bath
- Department of Internal Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, TN
| | - Sharif Kayali
- Department of Internal Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, TN
| | - Deya Alkhatib
- Department of Internal Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, TN
| | | | - Isaac Rhea
- Department of Internal Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, TN
| | - Rami N Khouzam
- Department of Internal Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, TN
| | - John L Jefferies
- Department of Internal Medicine, Division of Cardiovascular Diseases, University of Tennessee Health Science Center, Memphis, TN
| | - Mannu Nayyar
- Department of Cardiology, Regional One Health, Memphis, TN
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23
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Electrocardiographic features and need for pacemaker in cardiac amyloidosis: Analysis of 58 cases. Med Clin (Barc) 2022; 159:78-84. [PMID: 35074177 DOI: 10.1016/j.medcli.2021.09.022] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/27/2021] [Accepted: 09/02/2021] [Indexed: 11/22/2022]
Abstract
AIM Amyloidosis is a disease in which amyloid fibrils can be deposited in different cardiac structures, and several electrocardiographic abnormalities can be produced by this phenomenon. The objective of this study was to describe the most common basal electrocardiographic alterations in patients diagnosed with cardiac amyloidosis (CA) and to determine if these abnormalities have an impact on the need of pacemaker. METHODS This retrospective study included patients who had an established diagnosis of CA [light-chain cardiac amyloidosis (LA-CA) or transthyretin cardiac amyloidosis (TTR-CA)] between January 2013 and March 2021. The baseline heart rate, the percentage of patients with a pseudo-infarct pattern, low-voltage pattern or cardiac conductions disturbances, and the impact of these factors on the need of pacemaker were analysed. RESULTS Fifty-eight patients with CA (20 with LA-CA and 38 with TTR-CA) were included, and the majority were male (69.0%). Twenty-one patients had atrial fibrillation (AF) at diagnosis. Thirty-five patients had a pseudo-infarct pattern, 35% had a low-voltage pattern, and 22% had criteria for ventricular hypertrophy. Two hirds had a conduction disorder: 18 patients with first degree atrioventricular block, 12 right bundle branch block, 3 left bundle branch block and 25 with a branch hemiblock. There were no differences between LA-CA and TTR-CA. Patients with TTR-CA had a greater need for pacemakers in the folow-up (39±40 meses). Bundle branch block was a predictor of the need for a permanent pacemaker (HR: 23.43; CI 95%: 4.09.134.09; P=.01). CONCLUSIONS Electrocardiographic abnormalities in patients diagnosed wich CA are heterogeneus. Most frecuent is the presence of conduction disorders, the pseudoinfarction pattern, followed by the low voltage pattern. Patients with any bundle branch block at the baseline electrocardiogram need more frecuent to require a pacemaker during follow-up, especially in TTR-CA.
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24
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Pathology of sudden death, cardiac arrhythmias, and conduction system. Cardiovasc Pathol 2022. [DOI: 10.1016/b978-0-12-822224-9.00007-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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25
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Lioncino M, Monda E, Palmiero G, Caiazza M, Vetrano E, Rubino M, Esposito A, Salerno G, Dongiglio F, D'Onofrio B, Verrillo F, Cerciello G, Manganelli F, Pacileo G, Bossone E, Golino P, Calabrò P, Limongelli G. Cardiovascular Involvement in Transthyretin Cardiac Amyloidosis. Heart Fail Clin 2021; 18:73-87. [PMID: 34776085 DOI: 10.1016/j.hfc.2021.07.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Transthyretin cardiac amyloidosis (ATTR-CA) is a systemic disorder resulting from the extracellular deposition of amyloid fibrils of misfolded transthyretin protein in the heart. ATTR-CA is a life-threatening disease, which can be caused by progressive deposition of wild type transthyretin (wtATTR) or by aggregation of an inherited mutated variant of transthyretin (mATTR). mATTR Is a rare condition transmitted in an autosomal dominant manner with incomplete penetrance, causing heterogenous phenotypes which can range from predominant neuropathic involvement, predominant cardiomyopathy, or mixed. Diagnosis of ATTR-CA is complex and requires integration of different imaging tools (echocardiography, bone scintigraphy, magnetic resonance) with genetics, clinical signs, laboratory tests, and histology. In recent years, new therapeutic agents have shown good efficacy and impact on survival and quality of life in this subset of patients, nevertheless patients affected by ATTR-CA may still carry an unfavorable prognosis, thus highlighting the need for new therapies. This review aims to assess cardiovascular involvement, diagnosis, and management of patients affected by ATTR-CA.
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Affiliation(s)
- Michele Lioncino
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", AORN dei Colli, Monaldi Hospital, Naples, Italy
| | - Emanuele Monda
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", AORN dei Colli, Monaldi Hospital, Naples, Italy
| | - Giuseppe Palmiero
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", AORN dei Colli, Monaldi Hospital, Naples, Italy
| | - Martina Caiazza
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", AORN dei Colli, Monaldi Hospital, Naples, Italy
| | - Erica Vetrano
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", AORN dei Colli, Monaldi Hospital, Naples, Italy; Internal Medicine Unit, Department of Translational Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Marta Rubino
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", AORN dei Colli, Monaldi Hospital, Naples, Italy
| | - Augusto Esposito
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", AORN dei Colli, Monaldi Hospital, Naples, Italy
| | - Gemma Salerno
- Vanvitelli Cardiology Unit, Monaldi Hospital, Naples 80131, Italy
| | - Francesca Dongiglio
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", AORN dei Colli, Monaldi Hospital, Naples, Italy
| | - Barbara D'Onofrio
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", AORN dei Colli, Monaldi Hospital, Naples, Italy
| | - Federica Verrillo
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", AORN dei Colli, Monaldi Hospital, Naples, Italy
| | - Giuseppe Cerciello
- Haematology Unit, Department of Clinical Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Fiore Manganelli
- Department of Neuroscience, Reproductive Sciences and Odontostomatology, University of Naples 'Federico II', Via Pansini, 5, Naples 81025, Italy
| | - Giuseppe Pacileo
- Heart Failure and Cardiac Rehabilitation Unit, Department of Cardiology, AORN dei Colli, Monaldi Hospital, Naples, Italy
| | - Eduardo Bossone
- Division of Cardiology, "Antonio Cardarelli" Hospital, Naples 80131, Italy
| | - Paolo Golino
- Vanvitelli Cardiology Unit, Monaldi Hospital, Naples 80131, Italy; Department of Translational Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Paolo Calabrò
- Department of Translational Sciences, University of Campania "Luigi Vanvitelli", Naples, Italy; Division of Cardiology, A.O.R.N. "Sant'Anna & San Sebastiano", Caserta I-81100, Italy
| | - Giuseppe Limongelli
- Inherited and Rare Cardiovascular Disease Unit, Department of Translational Medical Sciences, University of Campania "Luigi Vanvitelli", AORN dei Colli, Monaldi Hospital, Naples, Italy; Institute of Cardiovascular Sciences, University College of London and St. Bartholomew's Hospital, London WC1E 6DD, UK.
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26
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Liżewska-Springer A, Królak T, Dorniak K, Kempa M, Dąbrowska-Kugacka A, Sławiński G, Lewicka E. Right Ventricular Endocardial Mapping and a Potential Arrhythmogenic Substrate in Cardiac Amyloidosis-Role of ICD. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph182111631. [PMID: 34770146 PMCID: PMC8583432 DOI: 10.3390/ijerph182111631] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 10/28/2021] [Accepted: 11/03/2021] [Indexed: 11/16/2022]
Abstract
Patients with cardiac amyloidosis (CA) have an increased risk of sudden cardiac death. (SCD). However, the role of an implantable cardioverter-defibrillator in the primary prevention of SCD in this group of patients is still controversial. We present a case with CA with recurrent syncope and non-sustained ventricular tachycardia. In order to further stratify the risk of SCD, an electrophysiological study with endocardial electroanatomic voltage mapping was performed prior to the ICD placement.
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Affiliation(s)
- Aleksandra Liżewska-Springer
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, 80-952 Gdansk, Poland; (T.K.); (M.K.); (A.D.-K.); (G.S.); (E.L.)
- Correspondence:
| | - Tomasz Królak
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, 80-952 Gdansk, Poland; (T.K.); (M.K.); (A.D.-K.); (G.S.); (E.L.)
| | - Karolina Dorniak
- Department of Nonivasive Cardiac Diagnostics, Medical University of Gdansk, 80-952 Gdansk, Poland;
| | - Maciej Kempa
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, 80-952 Gdansk, Poland; (T.K.); (M.K.); (A.D.-K.); (G.S.); (E.L.)
| | - Alicja Dąbrowska-Kugacka
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, 80-952 Gdansk, Poland; (T.K.); (M.K.); (A.D.-K.); (G.S.); (E.L.)
| | - Grzegorz Sławiński
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, 80-952 Gdansk, Poland; (T.K.); (M.K.); (A.D.-K.); (G.S.); (E.L.)
| | - Ewa Lewicka
- Department of Cardiology and Electrotherapy, Medical University of Gdansk, 80-952 Gdansk, Poland; (T.K.); (M.K.); (A.D.-K.); (G.S.); (E.L.)
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27
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Abstract
Systemic diseases can cause heart block owing to the involvement of the myocardium and thereby the conduction system. Younger patients (<60) with heart block should be evaluated for an underlying systemic disease. These disorders are classified into infiltrative, rheumatologic, endocrine, and hereditary neuromuscular degenerative diseases. Cardiac amyloidosis owing to amyloid fibrils and cardiac sarcoidosis owing to noncaseating granulomas can infiltrate the conduction system leading to heart block. Accelerated atherosclerosis, vasculitis, myocarditis, and interstitial inflammation contribute to heart block in rheumatologic disorders. Myotonic, Becker, and Duchenne muscular dystrophies are neuromuscular diseases involving the myocardium skeletal muscles and can cause heart block.
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28
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Alreshq R, Tugal D, Siddiqi O, Ruberg F. Conduction abnormalities and role of cardiac pacing in cardiac amyloidosis: A systematic review. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2021; 44:2092-2099. [PMID: 34632598 DOI: 10.1111/pace.14375] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 09/28/2021] [Accepted: 10/03/2021] [Indexed: 01/05/2023]
Abstract
Cardiac amyloidosis (CA) is an increasingly recognized cause of heart failure, characterized by extracellular deposition of insoluble protein fibrils leading to progressive myocardial dysfunction. The most common types of cardiac amyloidosis are immunoglobin light-chain (AL) and transthyretin (ATTR). Conduction abnormalities are commonly encountered among patients with cardiac amyloidosis and are an important cause of morbidity and mortality. Abnormalities range from infra-Hisian intraventricular conduction delay and bundle branch block to complete atrioventricular block. Pacemaker placement in CA patients follows established guidelines, similar to those for patients without CA, with generally good efficacy. The role and appropriate timing of pacemakers for primary prevention of brady-arrhythmias in CA remains uncertain. While biventricular (BiV) pacing has been shown to improve clinical outcomes in patients with systolic heart failure without CA, there are few data examining the utility of BiV pacing in patients with CA. With the advent of effective treatments for AL and ATTR, appropriate application of pacing is important to support patients with CA and conduction disease through therapeutic trials. This systematic review summarizes the current literature examining the utility of pacing in CA.
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Affiliation(s)
- Rabah Alreshq
- Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA.,Amyloidosis Center, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Derin Tugal
- Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Omar Siddiqi
- Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA.,Amyloidosis Center, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA
| | - Frederick Ruberg
- Section of Cardiovascular Medicine, Department of Medicine, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA.,Amyloidosis Center, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA.,Department of Radiology, Boston University School of Medicine, Boston Medical Center, Boston, Massachusetts, USA
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29
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Kim MM, Kolseth CM, Carlson D, Masri A. Clinical management of amyloid cardiomyopathy. Heart Fail Rev 2021; 27:1549-1557. [PMID: 34471997 DOI: 10.1007/s10741-021-10159-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/16/2021] [Indexed: 01/04/2023]
Abstract
Clinical heart failure, restrictive cardiomyopathy, and arrhythmias are hallmark features of amyloid cardiomyopathy. In contrast to the advancements in targeted therapies, there is a general lack of evidence-based practice guidelines for clinical management of amyloid cardiomyopathy. In this review, we review the role of routine medical therapy in amyloid cardiomyopathy, from heart failure management to orthostatic hypotension, atrial arrhythmias, thromboembolic complications, and prevention of sudden death. We conclude by discussing approaches to patients with end-stage disease.
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Affiliation(s)
- Morris M Kim
- Center for Amyloidosis, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Clinton M Kolseth
- Center for Amyloidosis, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Dayna Carlson
- Center for Amyloidosis, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA
| | - Ahmad Masri
- Center for Amyloidosis, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, OR, USA.
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30
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Jakaitė R, Pečeliūnas V, Aidietienė S, Bertašiūtė A, Bileišienė N, Mickevičiūtė O, Barysienė J. Electrocardiographic left ventricular strain pattern, ST-segment depression and atrial fibrillation at the time of diagnosis of systemic light chain amyloidosis: Incidence and clinical significance. J Electrocardiol 2021; 68:157-163. [PMID: 34455115 DOI: 10.1016/j.jelectrocard.2021.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2021] [Revised: 07/31/2021] [Accepted: 08/07/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND ST/T abnormalities recognized as electrocardiographic (ECG) left ventricular (LV) strain pattern are known as a marker of myocyte death and reduced survival. The purpose of this study was to determine whether ECG LV strain pattern, its components and atrial fibrillation (AF) predict lower survival at the time of diagnosis of systemic light chain (AL) amyloidosis. METHODS 12‑lead surface electrocardiogram (ECG), standard two-dimensional echocardiography, laboratory analyses were retrospectively evaluated within 2 months of diagnosis in 87 patients with biopsy-proven systemic AL amyloidosis from 2009 to 2017 in a single center. ECG strain pattern was defined as coexistence of ST-segment horizontal or downward sloping depression ≥0.05 mV at its most horizontal section and negative asymmetrical T-wave deeper than 0.1 mV in at least 1 of leads I,aVL,V1-V6. Patients with QRS >120 ms (BBB or major IVCD) were excluded from the analysis. RESULTS Kaplan-Meier survival analysis revealed a 1.8-fold shorter overall survival (OS) at 2 years in the ECG strain (21% of participants) group (p = 0.0078), 2.0-fold shorter OS in the ST-segment depression (STd) (isolated and strain related as one group) (34% of participants) group (p < 0.0001), and 3.9-fold shorter OS in AF (23% of participants) group (p < 0.0001) compared with those without. Median survival of patients with STd and AF were and 13.0 (range 1-74) and 9.5 (range 1-74) months respectively. In univariate analysis STd and AF were stronger predictors of inferior OS than relative wall thickness, average E/e' ratio, and LV ejection fraction, but weaker predictors of OS than B-type natriuretic peptide. In multivariate analysis STd and AF lost significance after adjustment for age, gender, number of organs involved and BNP. CONCLUSIONS ST-segment depression and AF were not significantly associated with reduced survival in AL amyloidosis at diagnosis.
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Affiliation(s)
- Rusnė Jakaitė
- Center of Cardiology and Angiology, Vilnius University Hospital Santaros Klinikos, Santariškių 2, LT-08661 Vilnius, Lithuania.
| | - Valdas Pečeliūnas
- Center of Haematology, Oncology and Transfusion Medicine, Vilnius University Hospital Santaros Klinikos, Santariškių 2, LT-08661 Vilnius, Lithuania; Faculty of Medicine, Vilnius University, Čiurlionio 21/27, LT-03101 Vilnius, Lithuania
| | - Sigita Aidietienė
- Center of Cardiology and Angiology, Vilnius University Hospital Santaros Klinikos, Santariškių 2, LT-08661 Vilnius, Lithuania; Faculty of Medicine, Vilnius University, Čiurlionio 21/27, LT-03101 Vilnius, Lithuania
| | - Agnė Bertašiūtė
- Center of Haematology, Oncology and Transfusion Medicine, Vilnius University Hospital Santaros Klinikos, Santariškių 2, LT-08661 Vilnius, Lithuania
| | - Neringa Bileišienė
- Center of Cardiology and Angiology, Vilnius University Hospital Santaros Klinikos, Santariškių 2, LT-08661 Vilnius, Lithuania
| | - Orinta Mickevičiūtė
- Center of Haematology, Oncology and Transfusion Medicine, Vilnius University Hospital Santaros Klinikos, Santariškių 2, LT-08661 Vilnius, Lithuania
| | - Jūratė Barysienė
- Center of Cardiology and Angiology, Vilnius University Hospital Santaros Klinikos, Santariškių 2, LT-08661 Vilnius, Lithuania; Faculty of Medicine, Vilnius University, Čiurlionio 21/27, LT-03101 Vilnius, Lithuania
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31
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Giamouzis G, Dimos A, Xanthopoulos A, Skoularigis J, Triposkiadis F. Left ventricular hypertrophy and sudden cardiac death. Heart Fail Rev 2021; 27:711-724. [PMID: 34184173 DOI: 10.1007/s10741-021-10134-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/22/2021] [Indexed: 12/31/2022]
Abstract
Sudden cardiac death (SCD) is among the leading causes of death worldwide, and it remains a public health problem, as it involves young subjects. Current guideline-directed risk stratification for primary prevention is largely based on left ventricular (LV) ejection fraction (LVEF), and preventive strategies such as implantation of a cardiac defibrillator (ICD) are justified only for documented low LVEF (i.e., ≤ 35%). Unfortunately, only a small percentage of primary prevention ICDs, implanted on the basis of a low LVEF, will deliver life-saving therapies on an annual basis. On the other hand, the vast majority of patients that experience SCD have LVEF > 35%, which is clamoring for better understanding of the underlying mechanisms. It is mandatory that additional variables be considered, both independently and in combination with the EF, to improve SCD risk prediction. LV hypertrophy (LVH) is a strong independent risk factor for SCD regardless of the etiology and the severity of symptoms. Concentric and eccentric LV hypertrophy, and even earlier concentric remodeling without hypertrophy, are all associated with increased risk of SCD. In this paper, we summarize the physiology and physiopathology of LVH, review the epidemiological evidence supporting the association between LVH and SCD, briefly discuss the mechanisms linking LVH with SCD, and emphasize the need to evaluate LV geometry as a potential risk stratification tool regardless of the LVEF.
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Affiliation(s)
- Grigorios Giamouzis
- Department of Cardiology, University General Hospital of Larissa, Larissa, Greece.,Department of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Apostolos Dimos
- Department of Cardiology, University General Hospital of Larissa, Larissa, Greece
| | - Andrew Xanthopoulos
- Department of Cardiology, University General Hospital of Larissa, Larissa, Greece
| | - John Skoularigis
- Department of Cardiology, University General Hospital of Larissa, Larissa, Greece.,Department of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece
| | - Filippos Triposkiadis
- Department of Cardiology, University General Hospital of Larissa, Larissa, Greece. .,Department of Medicine, School of Health Sciences, University of Thessaly, Larissa, Greece.
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32
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Zhang KW, Vallabhaneni S, Alvarez-Cardona JA, Krone RJ, Mitchell JD, Lenihan DJ. Cardiac Amyloidosis for the Primary Care Provider: A Practical Review to Promote Earlier Recognition of Disease. Am J Med 2021; 134:587-595. [PMID: 33444590 DOI: 10.1016/j.amjmed.2020.11.031] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 11/28/2020] [Accepted: 11/30/2020] [Indexed: 12/19/2022]
Abstract
Cardiac amyloidosis is increasingly recognized as an underdiagnosed cause of heart failure. Diagnostic delays of up to 3 years from symptom onset may occur, and patients may be evaluated by more than 5 specialists prior to receiving the correct diagnosis. Newly available therapies improve clinical outcomes by preventing amyloid fibril deposition and are usually more effective in early stages of disease, making early diagnosis essential. Better awareness among primary care providers of the clinical presentation and modern treatment landscape is essential to improve timely diagnosis and early treatment of this disease. In this review, we provide practical guidance on the epidemiology, clinical manifestations, diagnostic evaluation, and treatment of transthyretin and light chain cardiac amyloidosis to promote earlier disease recognition among primary care providers.
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Affiliation(s)
- Kathleen W Zhang
- Cardio-Oncology Center of Excellence, Washington University School of Medicine, St Louis Mo.
| | | | - Jose A Alvarez-Cardona
- Cardio-Oncology Center of Excellence, Washington University School of Medicine, St Louis Mo
| | - Ronald J Krone
- Cardio-Oncology Center of Excellence, Washington University School of Medicine, St Louis Mo
| | - Joshua D Mitchell
- Cardio-Oncology Center of Excellence, Washington University School of Medicine, St Louis Mo
| | - Daniel J Lenihan
- Cardio-Oncology Center of Excellence, Washington University School of Medicine, St Louis Mo
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33
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Liżewska-Springer A, Sławiński G, Lewicka E. Arrhythmic Sudden Cardiac Death and the Role of Implantable Cardioverter-Defibrillator in Patients with Cardiac Amyloidosis-A Narrative Literature Review. J Clin Med 2021; 10:1858. [PMID: 33922892 PMCID: PMC8123220 DOI: 10.3390/jcm10091858] [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: 02/26/2021] [Revised: 04/07/2021] [Accepted: 04/20/2021] [Indexed: 11/16/2022] Open
Abstract
Cardiac amyloidosis (CA) is considered to be associated with an increased risk of sudden cardiac death (SCD) due to ventricular tachyarrhythmias and electromechanical dissociation. However, current arrhythmic risk stratification and the role of an implantable cardioverter-defibrillator (ICD) for primary prevention of SCD remains unclear. This article provides a narrative review of the literature on electrophysiological abnormalities in the context of ventricular arrhythmias in patients with CA and the role of ICD in terms of survival benefit in this group of patients.
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Affiliation(s)
- Aleksandra Liżewska-Springer
- Department of Cardiology and Electrotherapy, Medical University of Gdańsk, 80-210 Gdańsk, Poland; (G.S.); (E.L.)
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34
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ÖMÜR SE, ZORLU Ç. Cardiac Amyloidosis in a Patient Presenting with Symptoms of Heart Failure. TURKISH JOURNAL OF INTERNAL MEDICINE 2021. [DOI: 10.46310/tjim.873267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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35
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Angsubhakorn N, Agdamag A, Sumransub N, Velangi P, Freund R, Martin CM, Alexy T. A case of AL amyloidosis presenting with refractory ventricular fibrillation. Respir Med Case Rep 2021; 32:101349. [PMID: 33552893 PMCID: PMC7851180 DOI: 10.1016/j.rmcr.2021.101349] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 11/28/2020] [Accepted: 01/13/2021] [Indexed: 11/25/2022] Open
Abstract
A 66-year-old male with recent diagnosis of heart failure with reduced ejection fraction was referred to our institution for management of cardiogenic/vasodilatory shock. During his evaluation, he suffered a sudden cardiac arrest from refractory ventricular tachycardia/fibrillation (VT/VF) despite normal electrolytes and no evidence of prior ventricular arrhythmias. He was placed on rescue peripheral veno-arterial extracorporeal membrane oxygenation support (VA-ECMO) for 4 days and was decannulated without end-organ damage. Continued workup revealed Mayo stage IV immunoglobulin light chain (AL) amyloidosis. Unfortunately, he developed acute cerebellar hemorrhage several days later. Autopsy findings were consistent with AL amyloidosis, with extensive cardiac fibrosis and amyloid deposition in the myocardium and vasculature. While the most common cause of cardiac death in patients with amyloidosis is severe bradycardia and pulseless electrical activity, sustained ventricular arrhythmias have been reported. The use of implantable cardioverter defibrillators (ICD) is highly debated in this population given the lack of survival benefit. Our patient also developed refractory VT/VF arrest, and ICD shocks would not have rescued him while causing significant distress. Emergent VA-ECMO cannulation allowed us to make a diagnosis, yet this intervention cannot be routinely recommended given the limited survival of patients with AL amyloidosis.
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Affiliation(s)
| | - Arianne Agdamag
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | | | - Pratik Velangi
- Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Robert Freund
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Cindy M Martin
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Tamas Alexy
- Division of Cardiology, Department of Medicine, University of Minnesota, Minneapolis, MN, USA
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Towbin JA, McKenna WJ, Abrams DJ, Ackerman MJ, Calkins H, Darrieux FCC, Daubert JP, de Chillou C, DePasquale EC, Desai MY, Estes NAM, Hua W, Indik JH, Ingles J, James CA, John RM, Judge DP, Keegan R, Krahn AD, Link MS, Marcus FI, McLeod CJ, Mestroni L, Priori SG, Saffitz JE, Sanatani S, Shimizu W, van Tintelen JP, Wilde AAM, Zareba W. 2019 HRS expert consensus statement on evaluation, risk stratification, and management of arrhythmogenic cardiomyopathy: Executive summary. Heart Rhythm 2020; 16:e373-e407. [PMID: 31676023 DOI: 10.1016/j.hrthm.2019.09.019] [Citation(s) in RCA: 120] [Impact Index Per Article: 30.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Indexed: 01/14/2023]
Abstract
Arrhythmogenic cardiomyopathy (ACM) is an arrhythmogenic disorder of the myocardium not secondary to ischemic, hypertensive, or valvular heart disease. ACM incorporates a broad spectrum of genetic, systemic, infectious, and inflammatory disorders. This designation includes, but is not limited to, arrhythmogenic right/left ventricular cardiomyopathy, cardiac amyloidosis, sarcoidosis, Chagas disease, and left ventricular noncompaction. The ACM phenotype overlaps with other cardiomyopathies, particularly dilated cardiomyopathy with arrhythmia presentation that may be associated with ventricular dilatation and/or impaired systolic function. This expert consensus statement provides the clinician with guidance on evaluation and management of ACM and includes clinically relevant information on genetics and disease mechanisms. PICO questions were utilized to evaluate contemporary evidence and provide clinical guidance related to exercise in arrhythmogenic right ventricular cardiomyopathy. Recommendations were developed and approved by an expert writing group, after a systematic literature search with evidence tables, and discussion of their own clinical experience, to present the current knowledge in the field. Each recommendation is presented using the Class of Recommendation and Level of Evidence system formulated by the American College of Cardiology and the American Heart Association and is accompanied by references and explanatory text to provide essential context. The ongoing recognition of the genetic basis of ACM provides the opportunity to examine the diverse triggers and potential common pathway for the development of disease and arrhythmia.
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Affiliation(s)
- Jeffrey A Towbin
- Le Bonheur Children's Hospital, Memphis, Tennessee; University of Tennessee Health Science Center, Memphis, Tennessee
| | - William J McKenna
- University College London, Institute of Cardiovascular Science, London, United Kingdom
| | | | | | | | | | | | | | | | | | - N A Mark Estes
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Wei Hua
- Fu Wai Hospital, Beijing, China
| | - Julia H Indik
- University of Arizona, Sarver Heart Center, Tucson, Arizona
| | - Jodie Ingles
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia
| | | | - Roy M John
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Daniel P Judge
- Medical University of South Carolina, Charleston, South Carolina
| | - Roberto Keegan
- Hospital Privado Del Sur, Buenos Aires, Argentina; Hospital Español, Bahia Blanca, Argentina
| | | | - Mark S Link
- UT Southwestern Medical Center, Dallas, Texas
| | - Frank I Marcus
- University of Arizona, Sarver Heart Center, Tucson, Arizona
| | | | - Luisa Mestroni
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Silvia G Priori
- University of Pavia, Pavia, Italy; European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-Heart); ICS Maugeri, IRCCS, Pavia, Italy
| | | | | | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - J Peter van Tintelen
- University of Amsterdam, Academic Medical Center, Amsterdam, the Netherlands; Utrecht University Medical Center Utrecht, University of Utrecht, Department of Genetics, Utrecht, the Netherlands
| | - Arthur A M Wilde
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-Heart); University of Amsterdam, Academic Medical Center, Amsterdam, the Netherlands; Department of Medicine, Columbia University Irving Medical Center, New York, New York
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37
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Bonderman D, Pölzl G, Ablasser K, Agis H, Aschauer S, Auer-Grumbach M, Binder C, Dörler J, Duca F, Ebner C, Hacker M, Kain R, Kammerlander A, Koschutnik M, Kroiss AS, Mayr A, Nitsche C, Rainer PP, Reiter-Malmqvist S, Schneider M, Schwarz R, Verheyen N, Weber T, Zaruba MM, Badr Eslam R, Hülsmann M, Mascherbauer J. Diagnosis and treatment of cardiac amyloidosis: an interdisciplinary consensus statement. Wien Klin Wochenschr 2020; 132:742-761. [PMID: 33270160 PMCID: PMC7732807 DOI: 10.1007/s00508-020-01781-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Accepted: 11/16/2020] [Indexed: 02/06/2023]
Abstract
The prevalence and significance of cardiac amyloidosis have been considerably underestimated in the past; however, the number of patients diagnosed with cardiac amyloidosis has increased significantly recently due to growing awareness of the disease, improved diagnostic capabilities and demographic trends. Specific therapies that improve patient prognosis have become available for certain types of cardiac amyloidosis. Thus, the earliest possible referral of patients with suspicion of cardiac amyloidosis to an experienced center is crucial to ensure rapid diagnosis, early initiation of treatment, and structured patient care. This requires intensive collaboration across several disciplines, and between resident physicians and specialized centers. The aim of this consensus statement is to provide guidance for the rapid and efficient diagnosis and treatment of light-chain amyloidosis and transthyretin amyloidosis, which are the most common forms of cardiac amyloidosis.
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Affiliation(s)
- Diana Bonderman
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria.
| | - Gerhard Pölzl
- Department of Medicine III (Cardiology and Angiology), Medical University of Innsbruck, Innsbruck, Austria
| | - Klemens Ablasser
- Division of Cardiology, Medical University of Graz, Graz, Austria
| | - Hermine Agis
- Department of Medicine I, Division of Hematology & Hemostaseology, Medical University of Vienna, Vienna, Austria
| | - Stefan Aschauer
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Michaela Auer-Grumbach
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna, Austria
| | - Christina Binder
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Jakob Dörler
- Department of Medicine III (Cardiology and Angiology), Medical University of Innsbruck, Innsbruck, Austria
| | - Franz Duca
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Christian Ebner
- Internal Department II of Cardiology, Angiology and Internal Intensive Medicine, Elisabethinen Hospital, Linz, Austria
| | - Marcus Hacker
- Division of Nuclear Medicine, Department of Biomedical Imaging and Image-guided Therapy, Department of Radiology and Nuclear Medicine, Medical University of Vienna, Vienna, Austria
| | - Renate Kain
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Andreas Kammerlander
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Matthias Koschutnik
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | | | - Agnes Mayr
- Department of Radiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Christian Nitsche
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Peter P Rainer
- Division of Cardiology, Medical University of Graz, Graz, Austria
| | | | - Matthias Schneider
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Roland Schwarz
- Specialist in Internal Medicine and Cardiology, Ried im Innkreis, Austria
| | - Nicolas Verheyen
- Division of Cardiology, Medical University of Graz, Graz, Austria
| | - Thomas Weber
- Department of Internal Medicine 2 (Cardiology & Intensive Care), University Teaching Hospital Klinikum Wels-Grieskirchen, Wels, Austria
| | - Marc Michael Zaruba
- Department of Medicine III (Cardiology and Angiology), Medical University of Innsbruck, Innsbruck, Austria
| | - Roza Badr Eslam
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Martin Hülsmann
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Julia Mascherbauer
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
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Gaba P, Pedrotty D, DeSimone CV, Bonikowske AR, Allison TG, Kapa S. Mortality in Patients With Right Bundle-Branch Block in the Absence of Cardiovascular Disease. J Am Heart Assoc 2020; 9:e017430. [PMID: 32924743 PMCID: PMC7792408 DOI: 10.1161/jaha.120.017430] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Background Right bundle-branch block (RBBB) occurs in 0.2% to 1.3% of people and is considered a benign finding. However, some studies have suggested increased risk of cardiovascular morbidity and mortality. We sought to evaluate risk attributable to incidental RBBB in patients without prior diagnosis of cardiovascular disease (CVD). Methods and Results We reviewed the Mayo Clinic Integrated Stress Center database for exercise stress tests performed from 1993 to 2010. Patients with no known CVD-defined as absence of coronary disease, structural heart disease, heart failure, or cerebrovascular disease-were selected. Only Minnesota residents were included, all of whom had full mortality and outcomes data. There were 22 806 patients without CVD identified; 220 of whom (0.96%) had RBBB, followed for 6 to 23 years (mean 12.4±5.1). There were 8256 women (36.2%), mean age was 52±11 years; and 1837 deaths (8.05%), including 645 cardiovascular-related deaths (2.83%), occurred over follow-up. RBBB was predictive of all-cause (hazard ratio [HR], 1.5; 95% CI, 1.1-2.0; P=0.0058) and cardiovascular-related mortality (HR,1.7; 95% CI, 1.1-2.8; P=0.0178) after adjusting for age, sex, diabetes mellitus, hypertension, obesity, current and past history of smoking, and use of a heart rate-lowering drug. Patients with RBBB exhibited more hypertension (34.1% versus 23.7%, P<0.0003), decreased functional aerobic capacity (82±25% versus 90±24%; P<0.0001), slower heart rate recovery (13.5±11.5 versus 17.1±9.4 bpm; P<0.0001), and more dyspnea (28.2% versus 22.4%; P<0.0399) on exercise testing. Conclusions Patients with RBBB without CVD have increased risk of all-cause mortality, cardiovascular-related mortality, and lower exercise tolerance. These data suggest RBBB may be a marker of early CVD and merit further prospective evaluation.
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Affiliation(s)
- Prakriti Gaba
- Department of Medicine Columbia University Medical Center New York NY
| | - Dawn Pedrotty
- Department of Medicine Hospital of the University of Pennsylvania Philadelphia PA
| | | | - Amanda R Bonikowske
- Department of Cardiovascular Medicine Mayo Clinic College of Medicine Rochester MN
| | - Thomas G Allison
- Department of Cardiovascular Medicine Mayo Clinic College of Medicine Rochester MN
| | - Suraj Kapa
- Department of Cardiovascular Medicine Mayo Clinic College of Medicine Rochester MN
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39
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Khanna S, Lo P, Cho K, Subbiah R. Ventricular Arrhythmias in Cardiac Amyloidosis: A Review of Current Literature. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2020; 14:1179546820963055. [PMID: 33088185 PMCID: PMC7545745 DOI: 10.1177/1179546820963055] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 09/06/2020] [Indexed: 01/29/2023]
Abstract
Cardiac Amyloidosis is an infiltrative cardiomyopathy which occurs secondary to deposition of mis-folded protein in the myocardium, with the two most common subtypes being AL amyloidosis and TTR amyloidosis. The pathogenesis of the disease is multifaceted and involves a variety of mechanisms including an inflammatory response cascade, oxidative stress and subsequent separation of myocyte fibrils. Cardiac Amyloidosis frequently results in congestive cardiac failure and arrhythmias, from a disruption in cardiac substrate with subsequent electro-mechanical remodelling. Disease progression is usually demonstrated by development of progressive pump failure, which may be seen with a high arrhythmic burden, usually portending a poor prognosis. There is a paucity of literature on the clinical implications of ventricular arrhythmias in the context of cardiac amyloidosis. The important diagnostic investigations for these patients include transthoracic echocardiography, cardiac magnetic resonance imaging and an electrophysiology study. Whilst there are no robust management guidelines, studies have indicated benefits from contemporary pharmacological therapy and case-by-case catheter ablation. There are novel directed therapies available for TTR amyloidosis that have shown to improve overall survival. The role of ICD therapy in cardiac amyloidosis is controversial, with benefits seen predominantly in early phases of the disease process. The only definitive surgical therapy includes heart transplantation, but is largely indicated for progressive decompensated heart failure (Figure 1). Further large-scale studies are required to better outline management paradigms for treating ventricular arrhythmias in cardiac amyloidosis.
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Affiliation(s)
- Shaun Khanna
- Department of Cardiology, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Phillip Lo
- Department of Cardiology, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Kenneth Cho
- Department of Cardiology, St Vincent's Hospital, Darlinghurst, NSW, Australia
| | - Rajesh Subbiah
- Department of Cardiology, St Vincent's Hospital, Darlinghurst, NSW, Australia.,University of New South Wales, Kensington, Sydney, NSW, Australia.,Victor Chang Cardiac Research Institute, Darlinghurst, NSW, Australia
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40
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Ashraf I, Peck MM, Maram R, Mohamed A, Ochoa Crespo D, Kaur G, Malik BH. Association of Arrhythmias in Cardiac Amyloidosis and Cardiac Sarcoidosis. Cureus 2020; 12:e9842. [PMID: 32953349 PMCID: PMC7497218 DOI: 10.7759/cureus.9842] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Cardiac involvement in amyloidosis and sarcoidosis is poorly understood, and is associated with high morbidity and mortality. Atrial and ventricular arrhythmias, along with conduction defects, are frequent in cardiac amyloidosis and sarcoidosis. Atrial dysfunction in cardiac amyloidosis may result in atrial fibrillation and increases the risk of stroke, making anticoagulation significant and challenging. Ventricular arrhythmia and conduction defects are more common in AL amyloidosis and cardiac sarcoidosis. Premature ventricular contractions (PVCs) from Purkinje fibers trigger ventricular arrhythmias in cardiac amyloidosis, while the inflammation and scarring leading to the reentrant process is the cause in cardiac sarcoidosis. The typical treatment modalities include Class II and III antiarrhythmic drugs and ablation techniques, while corticosteroids and immunosuppressants are indicated in cardiac sarcoidosis to reduce the burden of the disease and arrhythmias. Sudden cardiac death can be a manifestation of both disorders that can be prevented by the Implantable cardioverter-defibrillator (ICD), although the predictive risk factors for primary prevention remain uncertain. In this review, we addressed the current understanding of the pathways involved in inducing arrhythmias in cardiac amyloidosis and sarcoidosis-also, the complications including sudden death and stroke associated with arrhythmia in both diseases. We have discussed other preventive steps needed to minimize arrhythmias to provide symptomatic relief and palliation to patients.
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Affiliation(s)
- Ibtisam Ashraf
- Internal Medicine, Shalamar Institute of Health Sciences, Lahore, PAK.,Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Mercedes Maria Peck
- Internal Medicine, California Institute of Behavorial Neurosciences and Psychology, Fairfield, USA
| | - Ruchira Maram
- Internal Medicine, Arogyasri Healthcare Trust, Hyderabad, IND.,Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Alaa Mohamed
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA.,Internal Medicine, Memorial Hermann Medical Center, Houston, USA
| | - Diego Ochoa Crespo
- Internal Medicine, Clinica San Martin, Azogues, ECU.,Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Gurleen Kaur
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
| | - Bilal Haider Malik
- Internal Medicine, California Institute of Behavioral Neurosciences and Psychology, Fairfield, USA
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41
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Black-Maier E, Rehorn M, Loungani R, Friedman DJ, Alenezi F, Geurink K, Pokorney SD, Daubert JP, Sun AY, Atwater BD, Jackson KP, Hegland DD, Thomas KL, Bahnson TD, Khouri MG, Piccini JP. Catheter ablation of atrial fibrillation in cardiac amyloidosis. PACING AND CLINICAL ELECTROPHYSIOLOGY: PACE 2020; 43:913-921. [PMID: 32573789 DOI: 10.1111/pace.13992] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2020] [Revised: 05/20/2020] [Accepted: 06/21/2020] [Indexed: 12/19/2022]
Abstract
BACKGROUND Cardiac amyloidosis is a progressive infiltrative disease involving deposition of amyloid fibrils in the myocardium and cardiac conduction system that frequently manifests with heart failure (HF) and arrhythmias, most frequently atrial fibrillation (AF), atrial flutter (AFL), and atrial tachycardia (AT). METHODS We performed an observational retrospective study of patients with a diagnosis of cardiac amyloid who underwent catheter ablation at our institution between January 1, 2011 and December 1, 2018. Patient demographics, procedural characteristics, and outcomes were determined by manual chart review. RESULTS A total of 13 catheter ablations were performed over the study period in patients with cardiac amyloidosis, including 10 AT/AF/AFL ablations and three atrioventricular nodal ablations. Left ventricular ejection fraction was lower at the time of AV node ablation than catheter ablation of AT/AF/AFL (23% vs 40%, P = .003). Cardiac amyloid was diagnosed based on the results of preablation cardiac MRI results in the majority of patients (n = 7, 70%). The HV interval was prolonged at 60 ± 15 ms and did not differ significantly between AV nodal ablation patients and AT/AF/AFL ablation patients (69 ± 18 ms vs 57 ± 14 ms, P = .36). The majority of patients undergoing AT/AF/AFL ablation had persistent AF (n = 7, 70%) and NYHA class II (n = 5, 50%) or III (n = 5, 50%) HF symptoms, whereas patients undergoing AV node ablation were more likely to have class IV HF (n = 2, 66%, P = .014). Arrhythmia-free survival in CA patients after catheter ablation of AT/AF/AFL was 40% at 1 year and 20% at 2 years. CONCLUSIONS Catheter ablation of AT/AF/AFL may be a feasible strategy for appropriately selected patients with early to mid-stage CA, whereas AV node ablation may be more appropriate in patients with advanced-stage CA.
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Affiliation(s)
- Eric Black-Maier
- Division of Electrophysiology, Duke University Medical Center, Durham, North Carolina
| | - Michael Rehorn
- Division of Electrophysiology, Duke University Medical Center, Durham, North Carolina
| | - Rahul Loungani
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Daniel J Friedman
- Section of Cardiac Electrophysiology, Yale School of Medicine, New Haven, Connecticut
| | - Fawaz Alenezi
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Kyle Geurink
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Sean D Pokorney
- Division of Electrophysiology, Duke University Medical Center, Durham, North Carolina
| | - James P Daubert
- Division of Electrophysiology, Duke University Medical Center, Durham, North Carolina
| | - Albert Y Sun
- Division of Electrophysiology, Duke University Medical Center, Durham, North Carolina
| | - Brett D Atwater
- Division of Electrophysiology, Duke University Medical Center, Durham, North Carolina
| | - Kevin P Jackson
- Division of Electrophysiology, Duke University Medical Center, Durham, North Carolina
| | - Donald D Hegland
- Division of Electrophysiology, Duke University Medical Center, Durham, North Carolina
| | - Kevin L Thomas
- Division of Electrophysiology, Duke University Medical Center, Durham, North Carolina
| | - Tristram D Bahnson
- Division of Electrophysiology, Duke University Medical Center, Durham, North Carolina
| | - Michel G Khouri
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Jonathan P Piccini
- Division of Electrophysiology, Duke University Medical Center, Durham, North Carolina
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Barrett CD, Alexander KM, Zhao H, Haddad F, Cheng P, Liao R, Wheeler MT, Liedtke M, Schrier S, Arai S, Weisshaar D, Witteles RM. Outcomes in Patients With Cardiac Amyloidosis Undergoing Heart Transplantation. JACC-HEART FAILURE 2020; 8:461-468. [DOI: 10.1016/j.jchf.2019.12.013] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 12/16/2019] [Accepted: 12/17/2019] [Indexed: 01/01/2023]
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43
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Itzhaki Ben Zadok O, Kornowski R. Cardiac Care of Patients with Cardiac Amyloidosis. Acta Haematol 2020; 143:343-351. [PMID: 32408301 DOI: 10.1159/000506919] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2020] [Accepted: 02/28/2020] [Indexed: 12/20/2022]
Abstract
Cardiac amyloidosis, the majority of cases of which are due to immunoglobulin light chain amyloidosis (AL) and transthyretin amyloidosis (ATTR), affects different aspects of the heart and cardiovascular system. Amyloid-induced cardiomyopathy, clinically manifesting with heart failure and electrophysiological abnormalities, has distinct characteristics compared to non-amyloid cardiomyopathies. Accordingly, specific management strategies are required. This paper will review the cardiovascular manifestations of patients with cardiac amyloidosis and their suggested treatment strategies, emphasizing the importance of multidisciplinary care.
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Affiliation(s)
- Osnat Itzhaki Ben Zadok
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel,
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel,
| | - Ran Kornowski
- Department of Cardiology, Rabin Medical Center, Petah Tikva, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
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44
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Giancaterino S, Urey MA, Darden D, Hsu JC. Management of Arrhythmias in Cardiac Amyloidosis. JACC Clin Electrophysiol 2020; 6:351-361. [DOI: 10.1016/j.jacep.2020.01.004] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2019] [Revised: 12/28/2019] [Accepted: 01/09/2020] [Indexed: 12/16/2022]
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45
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Arrhythmias in Cardiac Amyloidosis: Challenges in Risk Stratification and Treatment. Can J Cardiol 2020; 36:416-423. [DOI: 10.1016/j.cjca.2019.11.039] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 11/08/2019] [Accepted: 11/18/2019] [Indexed: 12/16/2022] Open
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46
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El-Am EA, Dispenzieri A, Melduni RM, Ammash NM, White RD, Hodge DO, Noseworthy PA, Lin G, Pislaru SV, Egbe AC, Grogan M, Nkomo VT. Direct Current Cardioversion of Atrial Arrhythmias in Adults With Cardiac Amyloidosis. J Am Coll Cardiol 2020; 73:589-597. [PMID: 30732713 DOI: 10.1016/j.jacc.2018.10.079] [Citation(s) in RCA: 117] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Revised: 10/18/2018] [Accepted: 10/22/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND Arrhythmias, conduction abnormalities, and intracardiac thrombus are common in patients with cardiac amyloidosis (CA). Outcomes of direct-current cardioversion (DCCV) for atrial arrhythmias in patients with CA are unknown. OBJECTIVES This study sought to examine DCCV procedural outcomes in patients with CA. METHODS Patients with CA scheduled for DCCV for atrial arrhythmias from January 2000 through December 2012 were identified and matched 2:1 with control patients by age, sex, type of atrial arrhythmia, and date of DCCV. RESULTS CA patients (n = 58, mean age 69 ± 9 years, 81% male) were included. CA patients had a significantly higher cardioversion cancellation rate (28% vs. 7%; p < 0.001) compared with control patients, mainly due to intracardiac thrombus identified on transesophageal echocardiogram (13 of 16 [81%] vs. 2 of 8 [25%]; p = 0.02); 4 of 13 of the CA patients (31%) with intracardiac thrombus on transesophageal echocardiogram received adequate anticoagulation ≥3 weeks and another 2 of 13 (15%) had arrhythmia duration <48 h. DCCV success rate (90% vs. 94%; p = 0.4) was not different. Procedural complications were more frequent in CA versus control patients (6 of 42 [14%] vs. 2 of 106 [2%]; p = 0.007); complications in CA included ventricular arrhythmias in 2 and severe bradyarrhythmias requiring pacemaker implantation in 2. The only complication in the control group was self-limited bradyarrhythmias. CONCLUSIONS Patients with CA undergoing DCCV had a significantly high cancellation rate mainly due to a high incidence of intracardiac thrombus even among patients who received adequate anticoagulation. Although the success rate of restoring sinus rhythm was high, tachyarrhythmias and bradyarrhythmias complicating DCCV were significantly more frequent in CA patients compared with control patients.
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Affiliation(s)
- Edward A El-Am
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota. https://twitter.com/EdwardElAmm
| | | | - Rowlens M Melduni
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Naser M Ammash
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Roger D White
- Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota
| | - David O Hodge
- Biomedical Science and Informatics, Mayo Clinic, Jacksonville, Florida
| | - Peter A Noseworthy
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Grace Lin
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Sorin V Pislaru
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Alexander C Egbe
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota
| | - Martha Grogan
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota. https://twitter.com/MarthaGrogan1
| | - Vuyisile T Nkomo
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota.
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Karamitsos TD, Papanastasiou CA. Cardiac Magnetic Resonance T1 Mapping for Cardiac Amyloidosis. JACC Cardiovasc Imaging 2020; 13:81-82. [DOI: 10.1016/j.jcmg.2019.04.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 04/18/2019] [Indexed: 01/04/2023]
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John RM, Stern DL. Use of Implantable Electronic Devices in Patients With Cardiac Amyloidosis. Can J Cardiol 2019; 36:408-415. [PMID: 32037105 DOI: 10.1016/j.cjca.2019.12.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Revised: 12/03/2019] [Accepted: 12/03/2019] [Indexed: 10/25/2022] Open
Abstract
Arrhythmias are a major cause of morbidity and mortality in the course of cardiac amyloidosis (CA). Less commonly, they may be the initial manifestation that lead to the diagnosis. With improved therapeutic interventions for amyloidosis, it is no longer considered to be a terminal untreatable condition, and there is increasing recognition of the role of implantable electronic devices in CA. The frequency and nature of arrhythmias are largely determined by the type of amyloidosis. Bradyarrhythmias are more common in the transthyretin form of amyloidosis, and risk for ventricular arrhythmias is higher in the light-chain form. Pacemaker implantation is often required and effective for alleviation of symptoms. The role of implantable cardioverter-defibrillators (ICDs) remains controversial, especially for primary prevention of sudden death. Traditional risk stratification tools for sudden death do not appear to be applicable to CA, because decline of left ventricular (LV) systolic dysfunction to the point of the usual indication for an ICD implant in other cardiomyopathies, ie, LV ejection fraction ≤ 35%, usually marks end-stage disease in CA when pump failure becomes the predominant cause of death. The challenge remains the identification of markers for sudden death in early stages of the disease. Included in this review is a general overview of available data on the nature of bradycardia and ventricular arrhythmias, including the role of implantable electronic devices for the treatment of these conditions. Published series of ICD use in CA are summarized and the role of newer pacing techniques, including biventricular pacing, is discussed.
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Affiliation(s)
- Roy M John
- Center for Advanced Management of Ventricular Arrhythmias, Department of Cardiology, Northshore University Hospital, Manhasset, New York, USA.
| | - David L Stern
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA; Department of Cardiology, North Shore University Hospital, Manhasset, New York, USA
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He S, Tian Z, Guan H, Li J, Fang Q, Zhang S. Clinical characteristics and prognosis of Chinese patients with hereditary transthyretin amyloid cardiomyopathy. Orphanet J Rare Dis 2019; 14:251. [PMID: 31718691 PMCID: PMC6852775 DOI: 10.1186/s13023-019-1235-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 10/22/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Hereditary transthyretin amyloid cardiomyopathy (ATTR-CM) is an increasingly recognized progressive cardiomyopathy with heterogenous clinical manifestations that lead to its misdiagnosis and poor prognosis. This study was performed to describe the clinical characteristics and natural history of Chinese patients to improve clinical awareness of this condition. METHODS In this study, we retrospectively investigated 23 patients with a confirmed diagnosis of hereditary ATTR-CM in Peking Union Medical College hospital from From January 1, 2000 to December 31, 2018. RESULTS In all, 16 patients (69.6%) were males, the median age at disease onset was 45 (33,55) years old. The median duration from symptom onset to diagnosis was 30 (18,46) months. Phenotypes were classified as exclusively cardiac (n = 1, 4.3%) and mixed type (n = 22, 95.6%). The common mutations were Gly47Arg (7 patients [30.4%]) and Val30Ala (3 patients [13%]). Ventricular hypertrophy was observed in 23 (100%) patients, the mean thickness of the ventricular septum was 16.1 ± 3.9 mm, the mean thickness of the left ventricular posterior wall was 15.1 ± 2.8 mm. The mean left ventricle ejection fraction (LVEF) was 57.3 ± 11.9% and only 5 patients (21.7%) had LVEF < 50%. 18 (78.3%) patients had abnormal electrocardiography and the most common feature was pseudoinfarct pattern (56.5%). Overall survival at 12, 24, 36, 48, and 60 months after diagnosis was 77.8, 55.6, 38.9, 27.8, and 11.1%, respectively. Survival was better in patients with EF ≥50% than in those with EF < 50% [log Rank (Mantel-Cox), χ2 = 4.03, P = 0.045]. CONCLUSIONS The clinical characteristics of ATTR are heterogeneous: men are more likely to be affected and onset symptoms are not obvious in the heart and mainly include peripheral neuropathy and autonomic neuropathy; however, LV hypertrophy, especially a thick ventricular septum and posterior wall with preserved LVEF, are often detected on echocardiography. Abnormal ECG manifestations are common. The prognosis is poor, and patients with EF > 50% have better survival. Clinicians should be more aware of the complex clinical profile of ATTR amyloidosis to avoid misdiagnosis in practice.
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Affiliation(s)
- Shan He
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100005, China
| | - Zhuang Tian
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100005, China
| | - Hongzhi Guan
- Department of Neurology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100005, China
| | - Jian Li
- Department of Hematology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100005, China
| | - Quan Fang
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100005, China
| | - Shuyang Zhang
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, 100005, China.
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Chiengthong K, Lertjitbanjong P, Thongprayoon C, Bathini T, Sharma K, Prasitlumkum N, Mao MA, Cheungpasitporn W, Chokesuwattanaskul R. Arrhythmias in hematopoietic stem cell transplantation: A systematic review and meta-analysis. Eur J Haematol 2019; 103:564-572. [PMID: 31478231 DOI: 10.1111/ejh.13322] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Revised: 08/24/2019] [Accepted: 08/26/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND There are controversial data regarding the relationship between hematopoietic stem cell transplantation and arrhythmias. This meta-analysis was performed to evaluate the incidence of arrhythmias in patients following hematopoietic stem cell transplantation (HSCT). METHODS A literature search was conducted utilizing MEDLINE, EMBASE, and Cochrane Databases from inception through April 2019. Pooled incidence with 95% confidence interval (CI) were calculated using random-effects meta-analysis. The protocol for this meta-analysis is registered with PROSPERO (International Prospective Register of Systematic Reviews; no. CRD42019131833). RESULTS Thirteen studies consisting of 10,587 patients undergoing HSCT were enrolled in this systematic review. Overall, the pooled estimated incidence of all types of arrhythmias following HSCT was 7.2% (95% CI: 4.9%-10.5%). With respect to the most common type of arrhythmia, the pooled estimated incidence of atrial fibrillation/atrial flutter (AF/AFL) within 30 days following HSCT was 4.2% (95% CI: 1.7%-9.6%). Egger's regression test demonstrated no significant publication bias in this meta-analysis of post-HSCT arrhythmia incidence. CONCLUSION The overall estimated incidence of arrhythmias following HSCT was 7.2%. Future large scale studies are needed to further elucidate the significance and clinical impact of arrhythmias in post-HSCT patients.
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Affiliation(s)
- Kanhatai Chiengthong
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand.,King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | | | | | - Tarun Bathini
- Department of Internal Medicine, University of Arizona, Tucson, AZ, USA
| | - Konika Sharma
- Department of Internal Medicine, Bassett Medical Center, Cooperstown, NY, USA
| | - Narut Prasitlumkum
- University of Hawaii Internal Medicine Residency Program, Honolulu, HI, USA
| | - Michael A Mao
- Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | | | - Ronpichai Chokesuwattanaskul
- King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand.,Division of Cardiovascular Medicine, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
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