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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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Maury P, Sanchis K, Djouadi K, Cariou E, Delasnerie H, Boveda S, Fournier P, Itier R, Mondoly P, Voglimacci-Stephanopoli Q, Beneyto M, Dhanjal TS, Rollin A, Damy T, Lairez O, Lellouche N. Catheter ablation of atrial arrhythmias in cardiac amyloidosis: Impact on heart failure and mortality. PLoS One 2024; 19:e0301753. [PMID: 38578782 PMCID: PMC10997066 DOI: 10.1371/journal.pone.0301753] [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: 10/29/2022] [Accepted: 03/05/2024] [Indexed: 04/07/2024] Open
Abstract
BACKGROUND Atrial arrhythmias (AA) commonly affect patients with cardiac amyloidosis (CA) and are a contributing risk factor for the development of heart failure (HF). This study sought to investigate the long-term efficacy and impact of catheter ablation on HF progression in patients with CA and AA. METHODS Thirty-one patients with CA and AA undergoing catheter ablation were retrospectively included (transthyretin-ATTR CA 61% and light chain-AL CA 39%). AA subtypes included atrial fibrillation (AFib) in 22 (paroxysmal in 10 and persistent in 12), atrial flutter (AFl) in 17 and atrial tachycardia (AT) in 11 patients. Long-term AA recurrence rates were evaluated along with the impact of sinus rhythm (SR) maintenance on HF and mortality. RESULTS AA recurrence was observed in 14 patients (45%) at a median of 3.5 months (AFib n = 8, AT n = 6, AFl = 0). Post-cardioversion, medical therapy or catheter ablation, 10 patients (32%) remained in permanent AA. Over a median follow-up of 19 months, all-cause mortality was 39% (n = 12): 3 with end-stage HF, 5 due to late complications of CA, 1 sudden cardiac death, 1 stroke, 1 COVID 19 (and one unknown). With maintenance of SR following catheter ablation, significant reductions in serum creatinine and natriuretic peptide levels were observed with improvements in NYHA class. Two patients required hospitalization for HF in the SR maintenance cohort compared to 5 patients in the AA recurrence cohort (p = 0.1). All 3 patients with deaths secondary to HF had AA recurrence compared to 11 out of the 28 patients whom were long-term survivors or deaths not related to HF (p = 0.04). All-cause mortality was not associated with AA recurrence. CONCLUSION This study demonstrates moderate long-term efficacy of SR maintenance with catheter ablation for AA in patients with CA. Improvements in clinical and biological status with positive trends in HF mortality are observed if SR can be maintained.
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Affiliation(s)
- Philippe Maury
- Department of Cardiology, University Hospital Toulouse, Toulouse, France
- I2MC, INSERM UMR 1297, Toulouse, France
| | - Kevin Sanchis
- Department of Cardiology, University Hospital Toulouse, Toulouse, France
| | - Kamila Djouadi
- Department of Cardiology, University Hospital Henri Mondor, Creteil, France
| | - Eve Cariou
- Department of Cardiology, University Hospital Toulouse, Toulouse, France
| | - Hubert Delasnerie
- Department of Cardiology, University Hospital Toulouse, Toulouse, France
| | | | - Pauline Fournier
- Department of Cardiology, University Hospital Toulouse, Toulouse, France
| | - Romain Itier
- Department of Cardiology, University Hospital Toulouse, Toulouse, France
| | - Pierre Mondoly
- Department of Cardiology, University Hospital Toulouse, Toulouse, France
| | | | - Maxime Beneyto
- Department of Cardiology, University Hospital Toulouse, Toulouse, France
| | | | - Anne Rollin
- Department of Cardiology, University Hospital Toulouse, Toulouse, France
| | - Thibaud Damy
- Department of Cardiology, University Hospital Henri Mondor, Creteil, France
| | - Olivier Lairez
- Department of Cardiology, University Hospital Toulouse, Toulouse, France
| | - Nicolas Lellouche
- Department of Cardiology, University Hospital Henri Mondor, Creteil, France
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Mir T, Uddin M, Ulbeh TM, Perveiz E, Lohia P, Sattar Y, Abohashem S, Ullah W, Maganti K, Qureshi WT, Lakis N. Clinical Outcomes of Aortic Stenosis in Amyloidosis: A United States National Cohort Study. Heart Lung Circ 2024; 33:443-449. [PMID: 38036372 DOI: 10.1016/j.hlc.2023.09.019] [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: 08/31/2022] [Revised: 07/21/2023] [Accepted: 09/21/2023] [Indexed: 12/02/2023]
Abstract
BACKGROUND Literature regarding outcomes associated with surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) among amyloidosis (AM) with aortic stenosis (AS) is limited. OBJECTIVES We aim to study the mortality and in-hospital clinical outcomes among AM with AS associated with SAVR or TAVR. METHODS We performed a retrospective study of all hospitalisation encounters associated with a diagnosis of AM with AS, using the Nationwide Readmissions Database for the years 2012-2019. Primary outcomes were in-hospital mortality, and 30-day readmissions. RESULTS A total of 4,820 index hospitalisations of AS (mean age 78.35±10.11 years; female 37.76%) among AM were reported. Total 464 patients had mechanical intervention, 251 patients (54.1%) TAVR and 213 patients (45.9%) SAVR. A total of 317 patients (6.77%) with AS died; TAVR 4.4%, SAVR 11.9% (p=0.01) and 6.66% died among the subgroup who did not have any mechanical intervention. Higher complication rates were observed among patients who had SAVR than those who had TAVR including acute kidney injury (39.8% vs 22.4%; p=0.01), septic shock (12.1% vs 4.4%; p=0.05) and cardiogenic shock (22% vs 4.4%; p<0.001). Acute heart failure was higher among patients who had TAVR (40.2% vs 27.5%; p=0.04) than those who had SAVR. All conduction block and ischaemic stroke were similar between the two groups (p=0.09 and p=0.1). The overall 30-day readmission rate among AM with AS encounters was 16.82%, higher among TAVR compared to SAVR subgroups (21.25% vs 11.17%; p=0.001). CONCLUSIONS Among AM with AS hospitalisations, TAVR had mortality benefits compared to SAVR and non-mechanical intervention subgroups. Moreover, higher 30-day mortality rate were observed among SAVR subgroup, which may suggest that TAVR should be strongly considered in AM patients complicated by AS.
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Affiliation(s)
- Tanveer Mir
- Internal Medicine, Wayne State University, Detroit, MI, USA; Internal Medicine, Baptist Health System, Montgomery, AL, USA.
| | - Mohammed Uddin
- Internal Medicine, Wayne State University, Detroit, MI, USA
| | | | - Eskara Perveiz
- Internal Medicine, Baptist Health System, Montgomery, AL, USA
| | - Prateek Lohia
- Internal Medicine, Wayne State University, Detroit, MI, USA
| | - Yasar Sattar
- Cardiology Division, University of Virginia, Charlottesville, VA, USA
| | - Shady Abohashem
- Cardiology Division, Harvard Medical School Massachusetts General Hospital, Boston, MA, USA
| | - Waqas Ullah
- Cardiology Division, Thomas Jefferson University, PA, USA
| | | | - Waqas T Qureshi
- Cardiology Division, University of Massachusetts, Amherst, MA, USA
| | - Nasser Lakis
- Internal Medicine, Wayne State University, Detroit, MI, USA
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Çavuşoğlu Y, Başarıcı İ, Tüfekçioğlu O, Özpelit E, Özdemir E, Sivrikoz İA, Altay H, Değertekin M, Dinçer İ, İkitimur B, Kahveci G, Bozkurt MF, Erkılıç M, Kaya GÇ, Beksaç M, Salihoğlu A, Tokgözoğlu L. Current barriers and recommendations on the diagnosis of transthyretin amyloid cardiomyopathy: a Delphi study. Front Cardiovasc Med 2024; 11:1299261. [PMID: 38333414 PMCID: PMC10851939 DOI: 10.3389/fcvm.2024.1299261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 01/02/2024] [Indexed: 02/10/2024] Open
Abstract
Objectives This study has been conducted to investigate the non-invasive diagnostic journey of patients with a transthyretin amyloid cardiomyopathy (aTTR-CM) in Turkey, identify the challenges and uncertainties encountered on the path to diagnosis from the perspectives of expert physicians, and develop recommendations that can be applied in such cases. Methods This study employed a three-round modified Delphi method and included 10 cardiologists and five nuclear medicine specialists. Two hematologists also shared their expert opinions on the survey results related to hematological tests during a final face-to-face discussion. A consensus was reached when 80% or more of the panel members marked the "agree/strongly agree" or "disagree/strongly disagree" option. Results The panelists unanimously agreed that the aTTR-CM diagnosis could be established through scintigraphy (using either 99mTc-PYP, 99mTc-DPD, or 99mTc-HMPD) in a patient with suspected cardiac amyloidosis (CA) without a further investigation if AL amyloidosis is ruled out (by sFLC, SPIE and UPIE). In addition, scintigraphy imaging performed by SPECT or SPECT-CT should reveal a myocardial uptake of Grade ≥2 with a heart-to-contralateral (H/CL) ratio of ≥1.5. The cardiology panelists recommended using cardiovascular magnetic resonance (CMR) and a detailed echocardiographic scoring as a last resort before considering an endomyocardial biopsy in patients with suspected CA whose scintigraphy results were discordant/inconclusive or negative but still carried a high clinical suspicion of aTTR-CM. Conclusion The diagnostic approach for aTTR-CM should be customized based on the availability of diagnostic tools/methods in each expert clinic to achieve a timely and definitive diagnosis.
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Affiliation(s)
- Yüksel Çavuşoğlu
- Department of Cardiology, Eskisehir Osmangazi University Medical Faculty Hospital, Eskisehir, Turkey
| | - İbrahim Başarıcı
- Department of Cardiology, Akdeniz University Medical Faculty Hospital, Antalya, Turkey
| | - Omaç Tüfekçioğlu
- Department of Cardiology, University of Health Sciences Ankara City Hospital, Ankara, Turkey
| | - Ebru Özpelit
- Department of Cardiology, Dokuz Eylul University Medical Faculty Hospital, Izmir, Turkey
| | - Elif Özdemir
- Department of Nuclear Medicine, Ankara Yildirim Beyazit University, Ankara City Hospital, Ankara, Turkey
| | - İlknur Ak Sivrikoz
- Department of Nuclear Medicine, Eskişehir Osmangazi University Medical Faculty Hospital, Eskisehir, Turkey
| | - Hakan Altay
- Department of Cardiology, Baskent University Medical Faculty Hospital, Istanbul, Turkey
| | - Muzaffer Değertekin
- Department of Cardiology, Yeditepe University Medical Faculty Hospital, Istanbul, Turkey
| | - İrem Dinçer
- Department of Cardiology, Ankara University Medical Faculty Hospital, Ankara, Turkey
| | - Barış İkitimur
- Department of Cardiology, Istanbul University Medical Faculty Hospital, Istanbul, Turkey
| | - Gökhan Kahveci
- Department of Cardiology, Başakşehir Çam Sakura City Hospital, Istanbul, Turkey
| | - Murat Fani Bozkurt
- Department of Nuclear Medicine, Hacettepe University Medical Faculty Hospital, Ankara, Turkey
| | - Metin Erkılıç
- Department of Nuclear Medicine, Akdeniz University Medical Faculty Hospital, Antalya, Turkey
| | - Gamze Çapa Kaya
- Department of Nuclear Medicine, Dokuz Eylul University Medical Faculty Hospital, Izmir, Turkey
| | - Meral Beksaç
- Department of Internal Diseases, Division of Hematology, Ankara University Medical Faculty Hospital, Ankara, Turkey
| | - Ayşe Salihoğlu
- Department of Internal Diseases, Division of Hematology, Istanbul University Medical Faculty Hospital, Istanbul, Turkey
| | - Lale Tokgözoğlu
- Department of Cardiology, Hacettepe University Medical Faculty Hospital, Ankara, Turkey
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Mistrulli R, Ferrera A, Muthukkattil ML, Battistoni A, Gallo G, Barbato E, Spera FR, Magrì D. Atrial Fibrillation in Patients with Hypertrophic Cardiomyopathy and Cardiac Amyloidosis: From Clinical Management to Catheter Ablation Indication. J Clin Med 2024; 13:501. [PMID: 38256635 PMCID: PMC10816101 DOI: 10.3390/jcm13020501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 01/11/2024] [Accepted: 01/15/2024] [Indexed: 01/24/2024] Open
Abstract
Atrial fibrillation (AF) is the most common arrhythmia in patients affected by cardiomyopathies. Reports estimate a prevalence of 27% in patients with hypertrophic cardiomyopathy (HCM) and 40% in patients with cardiac amyloidosis (CA). The presence of AF typically results in progressive functional decline, an increased frequency of hospitalizations for heart failure, and a higher thromboembolic risk. Medical management using mainly beta-blockers or amiodarone has produced variable outcomes and a high rate of recurrence. Catheter ablation reduces symptom burden and complications despite a moderate rate of recurrence. Recent evidence suggests that an early rhythm control strategy may lead to more favorable short- and long-term outcomes. In this review, we summarize contemporary data on the management of AF in patients with cardiomyopathy (HCM and CA) with particular reference to the timing and outcomes of ablation procedures.
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Affiliation(s)
- Raffaella Mistrulli
- Clinical and Molecular Medicine Department, Sapienza University of Rome, 00185 Rome, Italy; (A.F.); (M.L.M.); (A.B.); (G.G.); (E.B.); (D.M.)
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Duca F, Rettl R, Kronberger C, Poledniczek M, Binder C, Dalos D, Koschutnik M, Donà C, Beitzke D, Loewe C, Nitsche C, Hengstenberg C, Badr-Eslam R, Kastner J, Bergler-Klein J, Kammerlander AA. Amyloid Burden Correlates with Electrocardiographic Findings in Patients with Cardiac Amyloidosis-Insights from Histology and Cardiac Magnetic Resonance Imaging. J Clin Med 2024; 13:368. [PMID: 38256502 PMCID: PMC10816127 DOI: 10.3390/jcm13020368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 12/28/2023] [Accepted: 01/05/2024] [Indexed: 01/24/2024] Open
Abstract
Cardiac amyloidosis (CA) is associated with several distinct electrocardiographic (ECG) changes. However, the impact of amyloid depositions on ECG parameters is not well investigated. We therefore aimed to assess the correlation of amyloid burden with ECG and test the prognostic power of ECG findings on outcomes in patients with CA. Consecutive CA patients underwent ECG assessment and cardiac magnetic resonance imaging (CMR), including the quantification of extracellular volume (ECV) with T1 mapping. Moreover, seven patients underwent additional amyloid quantification using immunohistochemistry staining of endomyocardial biopsies. A total of 105 CA patients (wild-type transthyretin: 74.3%, variant transthyretin: 8.6%, light chain: 17.1%) were analyzed for this study. We detected correlations of total QRS voltage with histologically quantified amyloid burden (r = -0.780, p = 0.039) and ECV (r = -0.266, p = 0.006). In patients above the ECV median (43.9%), PR intervals were significantly longer (p = 0.016) and left anterior fascicular blocks were more prevalent (p = 0.025). In our survival analysis, neither Kaplan-Meier curves (p = 0.996) nor Cox regression analysis detected associations of QRS voltage with adverse patient outcomes (hazard ratio: 0.995, p = 0.265). The present study demonstrated that an increased amyloid burden is associated with lower voltages in CA patients. However, baseline ECG findings, including QRS voltage, were not associated with adverse outcomes.
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Affiliation(s)
- Franz Duca
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - René Rettl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Christina Kronberger
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Michael Poledniczek
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Christina Binder
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Daniel Dalos
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Matthias Koschutnik
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Carolina Donà
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Dietrich Beitzke
- Division of Cardiovascular and Interventional Radiology, Department of Bioimaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria; (D.B.); (C.L.)
| | - Christian Loewe
- Division of Cardiovascular and Interventional Radiology, Department of Bioimaging and Image-Guided Therapy, Medical University of Vienna, 1090 Vienna, Austria; (D.B.); (C.L.)
| | - Christian Nitsche
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Christian Hengstenberg
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Roza Badr-Eslam
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Johannes Kastner
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Jutta Bergler-Klein
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
| | - Andreas Anselm Kammerlander
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, 1090 Vienna, Austria; (F.D.); (R.R.); (C.K.); (M.P.); (C.B.); (D.D.); (M.K.); (C.D.); (C.N.); (R.B.-E.); (J.K.); (J.B.-K.)
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7
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Zhou XY, Tang CX, Guo YK, Chen WC, Guo JZ, Ren GS, Li X, Li JH, Lu GM, Huang XH, Wang YN, Zhang LJ, Yang GF. Late gadolinium enhanced cardiac MR derived radiomics approach for predicting all-cause mortality in cardiac amyloidosis: a multicenter study. Eur Radiol 2024; 34:402-410. [PMID: 37552255 DOI: 10.1007/s00330-023-09999-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 05/03/2023] [Accepted: 06/05/2023] [Indexed: 08/09/2023]
Abstract
OBJECTIVES To evaluate the prognostic value of radiomics features based on late gadolinium enhancement (LGE) cardiac magnetic resonance (CMR) images in patients with cardiac amyloidosis (CA). METHODS This retrospective study included 120 CA patients undergoing CMR at three institutions. Radiomics features were extracted from global and three different segments (base, mid-ventricular, and apex) of left ventricular (LV) on short-axis LGE images. Primary endpoint was all-cause mortality. The predictive performance of the radiomics features and semi-quantitative and quantitative LGE parameters were compared by ROC. The AUC was used to observe whether Rad-score had an incremental value for clinical stage. The Kaplan-Meier curve was used to further stratify the risk of CA patients. RESULTS During a median follow-up of 12.9 months, 30% (40/120) patients died. There was no significant difference in the predictive performance of the radiomics model in different LV sections in the validation set (AUCs of the global, basal, middle, and apical radiomics model were 0.75, 0.77, 0.76, and 0.77, respectively; all p > 0.05). The predictive performance of the Rad-score of the base-LV was better than that of the LGE total enhancement mass (AUC:0.77 vs. 0.54, p < 0.001) and LGE extent (AUC: 0.77 vs. 0.53, p = 0.004). Rad-score combined with Mayo stage had better predictive performance than Mayo stage alone (AUC: 0.86 vs. 0.81, p = 0.03). Rad-score (≥ 0.66) contributed to the risk stratification of all-cause mortality in CA. CONCLUSIONS Compared to quantitative LGE parameters, radiomics can better predict all-cause mortality in CA, while the combination of radiomics and Mayo stage could provide higher predictive accuracy. CLINICAL RELEVANCE STATEMENT Radiomics analysis provides incremental value and improved risk stratification for all-cause mortality in patients with cardiac amyloidosis. KEY POINTS • Radiomics in LV-base was superior to LGE semi-quantitative and quantitative parameters for predicting all-cause mortality in CA. • Rad-score combined with Mayo stage had better predictive performance than Mayo stage alone or radiomics alone. • Rad-score ≥ 0.66 was associated with a significantly increased risk of all-cause mortality in CA patients.
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Affiliation(s)
- Xi Yang Zhou
- Department of Nuclear Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
- Department of Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
| | - Chun Xiang Tang
- Department of Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
| | - Ying Kun Guo
- Department of Radiology, West China Second University Hospital, Sichuan University, 20# South Renmin Road, Chengdu, 610041, Sichuan, China
| | - Wen Cui Chen
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, Jiangsu, China
| | - Jin Zhou Guo
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, Jiangsu, China
| | - Gui Sheng Ren
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, Jiangsu, China
| | - Xiao Li
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1, Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Jun Hao Li
- Department of Nuclear Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
- Department of Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
| | - Guang Ming Lu
- Department of Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
| | - Xiang Hua Huang
- National Clinical Research Center of Kidney Disease, Jinling Hospital, Nanjing University School of Medicine, Nanjing, 210002, Jiangsu, China
| | - Yi Ning Wang
- Department of Radiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, No. 1, Shuaifuyuan, Dongcheng District, Beijing, 100730, China
| | - Long Jiang Zhang
- Department of Radiology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China.
| | - Gui Fen Yang
- Department of Nuclear Medicine, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China.
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8
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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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9
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Duca F, Rettl R, Binder C, Dusik F, Schrutka L, Dalos D, Öztürk B, Capelle CD, Qin H, Dachs TM, Camuz Ligios L, Agis H, Kain R, Hengstenberg C, Badr-Eslam R, Kastner J, Bonderman D. Cardiac amyloidosis: a significant blind spot of the H2FPEF score. Panminerva Med 2023; 65:491-498. [PMID: 36789997 DOI: 10.23736/s0031-0808.22.04649-3] [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: 02/16/2023]
Abstract
BACKGROUND Cardiac amyloidosis (CA) often mimics heart failure with preserved ejection fraction (HFpEF). Due to very different treatment strategies, an exact diagnosis and differentiation between pure HFpEF and CA-related heart failure (HF) is important. In the present study, we assessed the recently published H2FPEF score in patients with pure HFpEF, transthyretin (ATTR), as well as light chain (AL) amyloidosis-related HFpEF and tested whether it differentiates between these entities. METHODS The H2FPEF scores consists of easy-to-assess clinical (Body Mass Index, number of hypertensive drugs, presence of atrial fibrillation, age) and echocardiographic (systolic pulmonary arterial pressure, E/E´) parameters. It can be computed in a categorical way resulting in scores between 0 and 9 points (0-1: HFpEF rule out, 2-5: further testing required, 6-9: HFpEF rule in), or in a continual way providing an exact percentage of a patient's HFpEF probability. Continuous and categorical variables were compared using the Kruskal-Wallis, Mann-Whitney-U, and χ2-tests. Diagnostic accuracy was computed from 2x2 tables. Survival analysis was performed with Kaplan-Meier curves. A P value of <0.05 was set as the level of significance. RESULTS A total of 100 patients with pure HFpEF, 53 patients with ATTR, and 34 patients with AL CA were included in the present study. Median age (HFpEF: 71.5 years; ATTR CA: 77.0 years; AL CA: 60.0 years; P<0.001), gender distribution (HFpEF [female]: 73.0%, ATTR (female): 18.9%, AL [female]: 38.2%; P<0.001), and N-terminal prohormone of brain natriuretic peptide (HFpEF: 1045pg/mL; ATTR CA: 1927pg/mL; AL CA: 4308pg/mL; P<0.001) differed significantly between study cohorts. Median H2FPEF scores were highest among HFpEF (categorical: 5.0 points; continual: 95.1%), followed by ATTR (categorical: 4.0 points; continual: 89.0%), and AL CA (categorical: 3.0 points; continual: 31.2%). Respective P values were <0.001. Low H2FPEF scores (0-1 points) were found among patients in the AL CA cohort (29.4%), but not among HFpEF or ATTR CA patients (P<0.001). The majority of patients, irrespective of disease entity were in the intermediate score range (2-5 points, HFpEF: 80.0% ATTR CA: 94.3%, AL CA: 67.9%; P=0.006). High scores (6-9 points) were most often found among HFpEF patients (20.0%), followed by ATTR CA (5.7%) and AL CA (2.9%), (P=0.007). CONCLUSIONS The H2FPEF score should be used with caution, as there is a significant overlap between HFpEF and CA-related HF.
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Affiliation(s)
- Franz Duca
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Rene Rettl
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Christina Binder
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Fabian Dusik
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Lore Schrutka
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Daniel Dalos
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Begüm Öztürk
- Division of Cardiology, Favoriten Clinic, Vienna, Austria
| | | | - Hong Qin
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Theresa M Dachs
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Luciana Camuz Ligios
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Hermine Agis
- Clinical Institute of Pathology, Medical University of Vienna, Vienna, Austria
| | - Renate Kain
- Division of Hematology, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Christian Hengstenberg
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Roza Badr-Eslam
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Johannes Kastner
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Diana Bonderman
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria -
- Division of Cardiology, Favoriten Clinic, Vienna, Austria
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10
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Zhan L, Jin T, Zhou J, Xu W, Chen Y, Mezzenga R. Fast Probing Amyloid Polymorphism via Nanopore Translocation. NANO LETTERS 2023; 23:9912-9919. [PMID: 37856435 DOI: 10.1021/acs.nanolett.3c02860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2023]
Abstract
Neurodegenerative diseases are characterized by the presence of cross-β-sheet amyloid fibrils and a rich mesoscopic polymorphism, requiring noninvasive detection with high fidelity. Here, we introduce a methodology that can probe via a sensitive synthetic nanopore the complex polymorphism of amyloid fibrils by an automated and fast screening protocol. Statistically analyzing the translocation events on two model amyloid systems derived from β-lactoglobulin and lysozyme allows extracting the cross-sectional configuration of hydrated amyloid fibrils from current block amplitude and correlating dwell time with fibril length. These findings are consistent with the amyloid polymorphs observed in solution by atomic force microscopy. Furthermore, the ionic current signal of a single translocation event can reveal abnormally aggregated conformations of amyloid fibrils without potential artifacts associated with microscopy methods. This study introduces an effective approach to physically discriminating and separating amyloid and may serve in the rapid diagnosis of early aggregating pathological amyloidosis.
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Affiliation(s)
- Lijian Zhan
- Laboratory of Biosensors and Bioelectronics, Institute for Biomedical Engineering, ETH Zürich, 8092 Zürich, Switzerland
- Jiangsu Key Laboratory for Design and Manufacture of Micro-Nano Biomedical Instruments, School of Mechanical Engineering, Southeast University, Nanjing 211189, China
| | - Tonghui Jin
- Department of Health Sciences and Technology, ETH Zürich, 8092 Zürich, Switzerland
| | - Jiangtao Zhou
- Department of Health Sciences and Technology, ETH Zürich, 8092 Zürich, Switzerland
| | - Wei Xu
- Jiangsu Key Laboratory for Design and Manufacture of Micro-Nano Biomedical Instruments, School of Mechanical Engineering, Southeast University, Nanjing 211189, China
| | - Yunfei Chen
- Jiangsu Key Laboratory for Design and Manufacture of Micro-Nano Biomedical Instruments, School of Mechanical Engineering, Southeast University, Nanjing 211189, China
| | - Raffaele Mezzenga
- Department of Health Sciences and Technology, ETH Zürich, 8092 Zürich, Switzerland
- Department of Materials, ETH Zürich, Wolfgang-Pauli-Strasse 10, 8093 Zürich, Switzerland
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11
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Moreno-Gázquez I, Pérez-Palacios R, Abengochea-Quílez L, Lahuerta Pueyo C, Roteta Unceta Barrenechea A, Andrés Gracia A, Aibar Arregui MA, Menao Guillén S. Targeted sequencing of selected functional genes in patients with wild-type transthyretin amyloidosis. BMC Res Notes 2023; 16:249. [PMID: 37784196 PMCID: PMC10546623 DOI: 10.1186/s13104-023-06491-z] [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: 03/19/2023] [Accepted: 09/03/2023] [Indexed: 10/04/2023] Open
Abstract
OBJECTIVE Wild-type transthyretin (ATTRwt) amyloidosis is caused by the misfolding and deposition of the transthyretin protein (TTR) in the absence of mutations in the TTR gene. Studies regarding the variant form of ATTR amyloidosis (ATTRv) suggest that the presence of single-nucleotide polymorphisms (SNP) in genes other than the TTR, may influence the development of the disease. However, other genetic factors involved in the aetiopathogenesis of ATTRwt are currently unknown. This work investigates the presence of sequence variants in genes selected for their possible impact on ATTRwt amyloidosis. To do so, targeted sequencing of 84 protein-coding genes was performed in a cohort of 27 patients diagnosed with ATTRwt. RESULTS After applying quality and frequency filtering criteria, 72 rare or novel genetic variants were found. Subsequent classification according to the ACMG-AMP criteria resulted in 17 variants classified as of uncertain significance in 14 different genes. To our knowledge, this is the first report associating novel gene variants with ATTRwt amyloidosis. In conclusion, this study provides potential insights into the aetiopathogenesis of ATTRwt amyloidosis by linking novel coding-gene variants with the occurrence of the disease.
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Affiliation(s)
- Inmaculada Moreno-Gázquez
- Department of Clinical Biochemistry, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain.
- Basic Research in Internal Medicine Group, GIIS-084 (IIS Aragón), Zaragoza, Spain.
| | - Raquel Pérez-Palacios
- Department of Anatomy, Embryology and Genetics, Veterinary Faculty, University of Zaragoza, Zaragoza, Spain
- Basic Research in Internal Medicine Group, GIIS-084 (IIS Aragón), Zaragoza, Spain
| | - Lucia Abengochea-Quílez
- Health Research Institute in Aragón, Zaragoza, Spain
- Department of Chemical and Environmental Engineering, Campus Río Ebro- Edificio I+D, University of Zaragoza, Zaragoza, Spain
- Basic Research in Internal Medicine Group, GIIS-084 (IIS Aragón), Zaragoza, Spain
| | - Carmen Lahuerta Pueyo
- Department of Clinical Biochemistry, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
- Basic Research in Internal Medicine Group, GIIS-084 (IIS Aragón), Zaragoza, Spain
| | - Ana Roteta Unceta Barrenechea
- Department of Nuclear Medicine, Multihospital Nuclear Medicine Clinical Unit of Aragón, Zaragoza, Spain
- Basic Research in Internal Medicine Group, GIIS-084 (IIS Aragón), Zaragoza, Spain
| | - Alejandro Andrés Gracia
- Department of Nuclear Medicine, Multihospital Nuclear Medicine Clinical Unit of Aragón, Zaragoza, Spain
- Basic Research in Internal Medicine Group, GIIS-084 (IIS Aragón), Zaragoza, Spain
| | - Miguel Angel Aibar Arregui
- Department of Internal Medicine, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
- Basic Research in Internal Medicine Group, GIIS-084 (IIS Aragón), Zaragoza, Spain
| | - Sebastián Menao Guillén
- Department of Clinical Biochemistry, Hospital Clínico Universitario Lozano Blesa, Zaragoza, Spain
- Basic Research in Internal Medicine Group, GIIS-084 (IIS Aragón), Zaragoza, Spain
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12
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Yu F, Cui Y, Shi J, Wang L, Zhou Y, Ye T, Ye Z, Yang J, Wang X. Association between the TAPSE to PASP ratio and short-term outcome in patients with light-chain cardiac amyloidosis. Int J Cardiol 2023; 387:131108. [PMID: 37307999 DOI: 10.1016/j.ijcard.2023.05.058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 04/11/2023] [Accepted: 05/30/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Amyloid light-chain cardiac amyloidosis (AL-CA) patients experiencing RV failure have a poorer prognosis. The echocardiographic ratio of tricuspid annular plane systolic excursion (TAPSE) to pulmonary arterial systolic pressure (PASP) serves as a non-invasive proxy for evaluating the coupling between the right ventricle (RV) and pulmonary circulation. The aim of this study was to assess the association between the TAPSE/PASP ratio and short-term outcome in patients with AL-CA. METHODS Seventy-one patients diagnosed with AL-CA were enrolled in this retrospective cohort study.Short-term outcome was defined as 6-month all-cause mortality. Receiver operating characteristic (ROC), logistic regression, and Kaplan-Meier analysis were used in this study. RESULTS Among seventy-one patients with AL-CA (mean age, 62 ± 8 years, 69% male), 17 (24%) died within the first 6 months (mean follow-up period 55 ± 48 days). Linear regression analysis indicated that the TAPSE/PASP ratio was correlated with RV global longitudinal strain (r = -0.655, p < 0.001), RV free wall thickness (r = -0.599, p < 0.001), and left atrial reservoir strain (r = 0.770, p < 0.001). The time-dependent ROC and the area under the curve (AUC) showed that the TAPSE/PASP ratio was a better predictor (AUC = 0.798; 95% confidence interval (CI): 0.677-0.929) of short-term outcome than TAPSE (AUC = 0.734; 95% CI: 0.585-0.882) and PASP (AUC: 0.730; 95% CI: 0.587-0.874). Multivariate logistic regression showed that patients with the worse TAPSE/PASP (< 0.47 mm/mmHg) and lower systolic blood pressure (< 100 mmHg) had the highest risk of dying. CONCLUSIONS The TAPSE/PASP ratio is associated with the short-term outcome of patients with AL-CA. The combination of TAPSE/PASP ratio < 0.474 mmHg and SBP < 100 mmHg could identify the subgroup of patients with AL-CA at elevated risk of poor prognosis.
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Affiliation(s)
- Fangcong Yu
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yawei Cui
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jiaran Shi
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Longbo Wang
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yunping Zhou
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Tianxin Ye
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Zhehao Ye
- Department of Neurosurgery, Shengzhou Traditional Chinese Medicine Hospital,Shengzhou, China
| | - Jinxiu Yang
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
| | - Xingxiang Wang
- Department of Cardiology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
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13
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Montero-Calle P, Flandes-Iparraguirre M, Kuebler B, Arán B, Larequi E, Anaut I, Coppiello G, Aranguren XL, Veiga A, Elorz MTB, de Yébenes MG, Gavira JJ, Prósper F, Iglesias-García O, Vega MMM. Generation of an induced pluripotent stem cell line (ESi107-A) from a transthyretin amyloid cardiomyopathy (ATTR-CM) patient carrying a p.Ser43Asn mutation in the TTR gene. Stem Cell Res 2023; 71:103189. [PMID: 37660554 DOI: 10.1016/j.scr.2023.103189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/12/2023] [Accepted: 08/21/2023] [Indexed: 09/05/2023] Open
Abstract
Transthyretin (TTR) amyloid cardiomyopathy (ATTR-CM) is a life-threatening disease caused by the abnormal production of misfolded TTR protein by liver cells, which is then released systemically. Its amyloid deposition in the heart is linked to cardiac toxicity and progression toward heart failure. A human induced pluripotent stem cell (iPSC) line was generated from peripheral blood mononuclear cells (PBMCs) from a patient suffering familial transthyretin amyloid cardiomyopathy carrying a c.128G>A (p.Ser43Asn) mutation in the TTR gene. This iPSC line offers a useful resource to study the disease pathophysiology and a cell-based model for therapeutic discovery.
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Affiliation(s)
| | | | - Bernd Kuebler
- Barcelona Stem Cell Bank, Regenerative Medicine Programme, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Hospital Duran i Reynals, Barcelona, Spain
| | - Begoña Arán
- Barcelona Stem Cell Bank, Regenerative Medicine Programme, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Hospital Duran i Reynals, Barcelona, Spain
| | - Eduardo Larequi
- Hematology and Cell Therapy, Clínica Universidad de Navarra, Pamplona, Spain
| | - Ilazki Anaut
- Regenerative Medicine Program, CIMA Universidad de Navarra, Pamplona, Spain
| | - Giulia Coppiello
- Regenerative Medicine Program, CIMA Universidad de Navarra, Pamplona, Spain
| | - Xabier L Aranguren
- Regenerative Medicine Program, CIMA Universidad de Navarra, Pamplona, Spain
| | - Anna Veiga
- Barcelona Stem Cell Bank, Regenerative Medicine Programme, Institut d'Investigació Biomèdica de Bellvitge (IDIBELL), Hospital Duran i Reynals, Barcelona, Spain
| | | | | | - Juan J Gavira
- Department of Cardiology, Clínica Universidad de Navarra, Pamplona, Spain; Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
| | - Felipe Prósper
- Regenerative Medicine Program, CIMA Universidad de Navarra, Pamplona, Spain; Hematology and Cell Therapy, Clínica Universidad de Navarra, Pamplona, Spain; Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain
| | - Olalla Iglesias-García
- Regenerative Medicine Program, CIMA Universidad de Navarra, Pamplona, Spain; Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain.
| | - Manuel M Mazo Vega
- Regenerative Medicine Program, CIMA Universidad de Navarra, Pamplona, Spain; Hematology and Cell Therapy, Clínica Universidad de Navarra, Pamplona, Spain; Instituto de Investigación Sanitaria de Navarra (IdiSNA), Pamplona, Spain.
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14
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Benjamin MM, Arora P, Munir MS, Darki A, Liebo M, Yu M, Syed MA, Kinno M. Association of Left Atrial Hemodynamics by Magnetic Resonance Imaging With Long-Term Outcomes in Patients With Cardiac Amyloidosis. J Magn Reson Imaging 2023; 57:1275-1284. [PMID: 35801623 DOI: 10.1002/jmri.28320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2022] [Revised: 06/10/2022] [Accepted: 06/10/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Left atrial (LA) function and strain patterns by magnetic resonance imaging (MRI) have been investigated as markers of several cardiovascular pathologies, including cardiac amyloidosis (CA). However, associations with clinical outcomes have not been investigated. PURPOSE To compare LA function and strain by MRI in CA patients to a matched cohort of patients without cardiovascular disease (CVD) and evaluate the association with long-term clinical outcomes in CA patients. STUDY TYPE Retrospective case control. POPULATION A total of 51 patients with CA and 51 age-, gender-, and race-matched controls without CVD who underwent MRI in sinus rhythm. FIELD STRENGTH/SEQUENCE ECG-gated balanced steady-state free precession sequence at 1.5 T. ASSESSMENT All measurements were completed by one investigator (M.M.B.). LA function and strain parameters were measured including LA indexed minimum and maximum volumes, LA reservoir (R), contractile (CT), and conduit (CD) strain. We compared groups after adjusting for age, hypertension, New York Heart Association class, modified staging system (troponin-I, BNP, estimated GFR) and left ventricular ejection fraction (LVEF) for an endpoint of all-cause mortality and a composite endpoint of heart failure hospitalization (HFH) or death. STATISTICAL TESTS Differences between groups were evaluated with t tests for continuous variables or χ2 tests for categorical variables. A multivariable regression model was used to assess the associations of the P values-two-sided tests-<0.05 were considered statistically significant. RESULTS CA patients with median follow up of 4.9 (8.5) months had significantly lower LA strain and higher LA volumes in comparison to the matched cohort. In the multivariable analysis, only LVEF was significantly associated with death while ƐCT (OR 0.6, CI: 0.41-0.89), indexed minimum LA volume (OR 1.06, CI: 1.02-1.13) and indexed maximum LA volume (OR 1.08, CI: 1.01-1.15) were significantly associated with the composite outcome of death or HFH. CONCLUSION In this retrospective study of CA patients, ƐCT and indexed minimum and maximum LA volumes were significantly associated with the composite outcome of death or HFH. EVIDENCE LEVEL 3 TECHNICAL EFFICACY: Stage 3.
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Affiliation(s)
- Mina M Benjamin
- Division of Cardiovascular Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Punit Arora
- Department of Internal Medicine, Loyola University Medical Center, Maywood, Illinois, USA
| | - Muhammad S Munir
- Department of Internal Medicine, Loyola University Medical Center, Maywood, Illinois, USA
| | - Amir Darki
- Division of Cardiovascular Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Max Liebo
- Department of Cardiology, Loyola University Chicago, Stritch School of Medicine, Loyola University Medical Center, Maywood, Illinois, USA
| | - Mingxi Yu
- Department of Cardiology, Loyola University Chicago, Stritch School of Medicine, Loyola University Medical Center, Maywood, Illinois, USA
| | - Mushabbar A Syed
- Division of Cardiovascular Medicine, Loyola University Medical Center, Maywood, Illinois
| | - Menhel Kinno
- Division of Cardiovascular Medicine, Loyola University Medical Center, Maywood, Illinois
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15
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Giannopoulos AA, Buechel RR, Kaufmann PA. Coronary microvascular disease in hypertrophic and infiltrative cardiomyopathies. J Nucl Cardiol 2023; 30:800-810. [PMID: 35915323 PMCID: PMC10125945 DOI: 10.1007/s12350-022-03040-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 05/20/2022] [Indexed: 11/30/2022]
Abstract
Pathologic hypertrophy of the cardiac muscle is a commonly encountered phenotype in clinical practice, associated with a variety of structural and non-structural diseases. Coronary microvascular disease is considered to play an important role in the natural history of this pathological phenotype. Non-invasive imaging modalities, most prominently positron emission tomography and cardiac magnetic resonance, have provided insights into the pathophysiological mechanisms of the interplay between hypertrophy and the coronary microvasculature. This article summarizes the current knowledge on coronary microvascular dysfunction in the most frequently encountered forms of pathologic hypertrophy.
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Affiliation(s)
- Andreas A Giannopoulos
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital and University Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Ronny R Buechel
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital and University Zurich, Raemistrasse 100, 8091, Zurich, Switzerland
| | - Philipp A Kaufmann
- Department of Nuclear Medicine, Cardiac Imaging, University Hospital and University Zurich, Raemistrasse 100, 8091, Zurich, Switzerland.
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16
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Kraus MJ, Smits JM, Meyer AL, Strelniece A, van Kins A, Boeken U, Reinecke A, Provaznik Z, Van Caenegem O, Ancion A, Berchtold-Herz M, Van Cleemput JJA, Haverich A, Laufer G, Gummert J, Karck M, Warnecke G, Raake PW, Frey N, Kreusser MM. Outcomes in patients with cardiac amyloidosis undergoing heart transplantation: the eurotransplant experience. J Heart Lung Transplant 2023; 42:778-785. [PMID: 36710093 DOI: 10.1016/j.healun.2023.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Revised: 12/14/2022] [Accepted: 01/04/2023] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND When advanced heart failure occurs in cardiac amyloidosis, prognosis is poor. In this setting heart transplantation (HTX) is a treatment option for selected patients. We here present the results of post-transplantation outcomes in cardiac amyloidosis within the Eurotransplant area, investigating possible predictors of survival. METHODS Of 115 patients undergoing HTX due to cardiac amyloidosis in the Eurotransplant region between November 1987 and May 2020, detailed assessment prior to transplantation was available in 85 patients. The present study was conducted in a retrospective approach. Primary endpoint was mortality after HTX. Baseline variables were entered in a Cox proportional hazards model with the primary endpoint as a dependent variable. RESULTS Median overall survival following HTX was 6.3 years in the overall collective and the subgroup. Univariate Cox proportional hazards model revealed a significant relationship between overall survival and the transplantation period (2008 to 2020 vs 1987 to 2007; median survival 9.7 years vs 1.8 years, hazard ratio 0.45, p = 0.01). Further predictors were albumin concentration (hazard ratio 0.92, p < 0.001), and systolic blood pressure (hazard ratio 0.96, p < 0.001). The transplant period as well as albumin concentration remained significant independent predictors in the AL sub cohort in a multivariate Cox proportional hazards model. CONCLUSIONS HTX is a viable treatment option for patients at an advanced stage of cardiac amyloidosis as overall survival after transplantation has improved in the modern age. Patients at a very advanced stage of the disease, indicated by low serum albumin and blood pressure, show worse outcomes following HTX. Optimal timing and careful patient selection may therefore be particularly important to further improve post-HTX survival in amyloidosis patients.
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Affiliation(s)
- Martin J Kraus
- Department of Internal Medicine III, Division of Cardiology, University of Heidelberg, Heidelberg, Germany.
| | | | - Anna L Meyer
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | | | | | - Udo Boeken
- Department of Cardiac Surgery, Medical Faculty and University Hospital Duesseldorf, Heinrich-Heine-University, Duesseldorf, Germany
| | - Alexander Reinecke
- Department of Cardiology, Angiology and Intensive Care, University of Kiel, Kiel, Germany
| | - Zdenek Provaznik
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Regensburg, Germany
| | - Oliver Van Caenegem
- Cardiovascular Department, Intensive Care Unit, Cliniques Universitaires Saint-Luc, Bruxelles, Belgium (deceased)
| | - Arnaud Ancion
- Cardiology, Centre Hospitalier Universitaire Sart-Tilman, Liège, Belgium
| | - Michael Berchtold-Herz
- Department of Cardiovascular Surgery, University Heart Center Freiburg, Bad Krozingen, Freiburg, Germany; Department of Medicine, University Heart Center Freiburg, Freiburg, Germany
| | | | - Axel Haverich
- Department of Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Guenther Laufer
- Department of Cardiac Surgery, Vienna General Hospital, Medical University of Vienna, Vienna, Austria
| | - Jan Gummert
- Heart and Diabetes Center Nord-Rhein-Westfalen, Ruhr University Bochum, Bochum, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Gregor Warnecke
- Department of Cardiac Surgery, University of Heidelberg, Heidelberg, Germany
| | - Philip W Raake
- Department of Internal Medicine III, Division of Cardiology, University of Heidelberg, Heidelberg, Germany; DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany; Department of Cardiology, University Hospital of Augsburg, Augsburg Germany
| | - Norbert Frey
- Department of Internal Medicine III, Division of Cardiology, University of Heidelberg, Heidelberg, Germany; DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany
| | - Michael M Kreusser
- Department of Internal Medicine III, Division of Cardiology, University of Heidelberg, Heidelberg, Germany; DZHK (German Center for Cardiovascular Research), partner site Heidelberg/Mannheim, Heidelberg, Germany
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Sohail A, Ashiq U. Quantum inspired improved AI computing for the sensors of cardiac mechano-biology. SENSORS INTERNATIONAL 2022. [DOI: 10.1016/j.sintl.2022.100212] [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: 12/24/2022] Open
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18
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Maisuradze N, Ghanie N, Kurnick A, Gooden M, Ahmed R. Decompensated Heart Failure as the Initial Presentation of Multiple Myeloma: A Case Report. Cureus 2022; 14:e29658. [PMID: 36320971 PMCID: PMC9612592 DOI: 10.7759/cureus.29658] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/27/2022] [Indexed: 11/24/2022] Open
Abstract
Amyloid deposition in the setting of multiple myeloma (MM) is a well-documented phenomenon. In this paper, we present the rare case of a 62-year-old male who presented with decompensated heart failure in the setting of cardiac amyloid deposition as the initial presentation of MM. The patient presented to the emergency department with two weeks of worsening lower extremity edema. Laboratory exam revealed elevated troponin I, elevated B-type natriuretic peptide (BNP), macrocytosis, increased urine protein/creatinine ratio, and a monoclonal peak on both serum protein electrophoresis (SPEP) and urine protein electrophoresis (UPEP). Transthoracic echocardiogram (TTE) revealed findings suggestive of amyloidosis. Abdominal fat pad biopsy confirmed amyloid deposition. The patient did not have other symptoms typically seen in multiple myeloma, such as fatigue or weakness, bone pain, or weight loss. In conclusion, we present a rare case of decompensated heart failure in the setting of amyloidosis as the initial presentation of multiple myeloma.
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19
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Quinn JH, Sviggum EB, La Nou AT, Burkhamer KJ. Point-of-care ultrasound leads to a rare incidental diagnosis in a patient with acute kidney injury. JAAPA 2022; 35:35-39. [PMID: 35762954 DOI: 10.1097/01.jaa.0000824924.04938.e4] [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: 11/27/2022]
Abstract
ABSTRACT Cardiac amyloidosis is a rare disorder with a poor long-term prognosis. Presenting features often mirror those of more commonly encountered diseases, making diagnosis challenging. Clinicians should suspect amyloidosis in patients presenting with symptoms of heart failure and preserved ejection fraction. Diagnostic testing assesses for characteristic ECG, echocardiogram, and cardiovascular MRI findings. Confirmatory testing traditionally is performed with endomyocardial biopsy, but safer, less-invasive options exist. Although overall prognosis is unfavorable, contemporary advances in treatment options have improved short-term patient survival.
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Affiliation(s)
- Jesse H Quinn
- At the Mayo Clinic Health System in Eau Claire, Wis., Jesse H. Quinn practices in emergency medicine, Erik B. Sviggum is a radiologist, Abigail T. La Nou practices in emergency medicine and critical care medicine, and Kyle J. Burkhamer practices in emergency medicine. The authors have disclosed no potential conflicts of interest, financial or otherwise
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20
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Banydeen R, Signate A, Tran TH, Monfort A, Neviere R, Inamo J. Cerebral Ischemic Events: An Overlooked Complication of Transthyretin Cardiac Amyloidosis in Afro-Caribbean Patients. Front Neurol 2022; 13:878292. [PMID: 35665045 PMCID: PMC9161261 DOI: 10.3389/fneur.2022.878292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 04/06/2022] [Indexed: 11/13/2022] Open
Abstract
AimThe link between transthyretin cardiac amyloidosis (CATTR), and cerebral ischemic events (CIE) has only been hinted at till now, impeding progress in patient management. We seek to evaluate the frequency and characteristics of CIE in Afro-Caribbean patients followed for CATTR at our institution.MethodsIn this single-center retrospective observational study, Afro-Caribbean patients followed for CATTR between July 2005 and October 2019 were included. Occurrence of CIE was investigated, and their cardioembolic origin determined. Analysis of patient characteristics was conducted according to CIE and CATTR profiles.ResultsOverall, 120 CATTR patients were included: 17 wild-type ATTR (14.2%), 73 ATTR-V122I (60.8%), and 22 ATTR-I107V (18.3%). Thirty-six patients (30.0%) presented with CIE, including three transient ischemic attacks and 33 permanent ischemic strokes (75.8% with a cardioembolic pattern). CIE was concomitant with CATTR diagnosis in 16 (16/36: 44.4%) patients, while 14 patients (14/36: 38.9 %) experienced CIE over a median CATTR follow-up of 2.0 years (min-max range: 0.8–4.4 years). CATTR-CIE patients presented with atrial fibrillation (66.7%), left atrial enlargement (77.8%), a CHA2DS2-VASc ≥ 3 (97.2%) and a high anticoagulant intake (75.0%). Multivariate analysis retained only a high CHA2DS2-VASc score as an independent predictor of CIE risk (Hazard Ratio [95% CI]: 12.03 [1.62–89.24]).ConclusionConcomitant CIE, and CATTR diagnosis, potentially carries a worse prognosis. A CHA2DS2-VASc score ≥3 seems to be a strong and independent predictive factor of CIE in CATTR patients. Further studies are needed to assess the efficacy and timeliness of anticoagulation in CATTR patients, independently of atrial fibrillation.
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Affiliation(s)
- Rishika Banydeen
- Clinical Research Department, CHU Martinique (University Hospital of Martinique), Fort de France, France
- Cardiovascular Research Team EA7525, Université des Antilles (University of the French West Indies), Fort de France, France
| | - Aissatou Signate
- Department of Neurology, CHU Martinique (University Hospital of Martinique), Fort de France, France
| | - Tuan-Huy Tran
- Department of Neurology, CHU Martinique (University Hospital of Martinique), Fort de France, France
| | - Astrid Monfort
- Cardiovascular Research Team EA7525, Université des Antilles (University of the French West Indies), Fort de France, France
- Department of Cardiology, CHU Martinique (University Hospital of Martinique), Fort de France, France
| | - Remi Neviere
- Cardiovascular Research Team EA7525, Université des Antilles (University of the French West Indies), Fort de France, France
- Department of Cardiology, CHU Martinique (University Hospital of Martinique), Fort de France, France
- *Correspondence: Remi Neviere
| | - Jocelyn Inamo
- Cardiovascular Research Team EA7525, Université des Antilles (University of the French West Indies), Fort de France, France
- Department of Cardiology, CHU Martinique (University Hospital of Martinique), Fort de France, France
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21
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New Advanced Imaging Parameters and Biomarkers—A Step Forward in the Diagnosis and Prognosis of TTR Cardiomyopathy. J Clin Med 2022; 11:jcm11092360. [PMID: 35566485 PMCID: PMC9101617 DOI: 10.3390/jcm11092360] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Revised: 04/13/2022] [Accepted: 04/19/2022] [Indexed: 11/17/2022] Open
Abstract
Transthyretin amyloid cardiomyopathy (ATTR-CM) is an infiltrative disorder characterized by extracellular myocardial deposits of amyloid fibrils, with poor outcome, leading to heart failure and death, with significant treatment expenditure. In the era of a novel therapeutic arsenal of disease-modifying agents that target a myriad of pathophysiological mechanisms, timely and accurate diagnosis of ATTR-CM is crucial. Recent advances in therapeutic strategies shown to be most beneficial in the early stages of the disease have determined a paradigm shift in the screening, diagnostic algorithm, and risk classification of patients with ATTR-CM. The aim of this review is to explore the utility of novel specific non-invasive imaging parameters and biomarkers from screening to diagnosis, prognosis, risk stratification, and monitoring of the response to therapy. We will summarize the knowledge of the most recent advances in diagnostic, prognostic, and treatment tailoring parameters for early recognition, prediction of outcome, and better selection of therapeutic candidates in ATTR-CM. Moreover, we will provide input from different potential pathways involved in the pathophysiology of ATTR-CM, on top of the amyloid deposition, such as inflammation, endothelial dysfunction, reduced nitric oxide bioavailability, oxidative stress, and myocardial fibrosis, and their diagnostic, prognostic, and therapeutic implications.
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22
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Salinas-Arce J, Alca-Clares R, Gonzales-Luna AC, Cabrera-Saldaña M, Mendoza-Novoa P, Solórzano-Altamirano P, Guevara-Valdivia M. [Cardiac arrhythmias and amyloidosis]. ARCHIVOS PERUANOS DE CARDIOLOGIA Y CIRUGIA CARDIOVASCULAR 2022; 3:82-97. [PMID: 37351307 PMCID: PMC10284580 DOI: 10.47487/apcyccv.v3i2.217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 06/27/2022] [Indexed: 06/24/2023]
Abstract
Cardiac amyloidosis (CA) is a form of cardiomyopathy characterized by the extracellular deposit of protein fibers in the myocardium, leading to the development of heart failure, arrhythmias, and electrical conduction system alterations. It is known that most cardiomyopathies have a close relationship with heart rhythm abnormalities, however, CA is specially related to different kinds of arrhythmias even in pre-diagnosis stages. Arrhythmias like atrial fibrillation are present in up to 70% of patients with CA associated with a high risk of cardioembolic complications independent of the risk stratification. Ventricular arrhythmias are frequent, but the use of implantable cardioverter defibrillator has not been demonstrated to improve survival. The Atrial-Ventricular node disease is also common, and is frequently associated with the implantation of a pacemaker, even in asymptomatic patients. In this review, we clarify the recommendations of the most current guidelines, summarize historical and contemporaneous data and describe evidence-based strategies for the management of arrhythmias and their complications in CA.
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Affiliation(s)
- Jorge Salinas-Arce
- Unidad de Arritmias, Clínica Delgado. Lima, Perú.Unidad de ArritmiasClínica DelgadoLimaPerú
| | - Raúl Alca-Clares
- Unidad de Arritmias, Clínica Delgado. Lima, Perú.Unidad de ArritmiasClínica DelgadoLimaPerú
- . Servicio de Cardiología, Hospital Cayetano Heredia. Lima, Perú.Servicio de CardiologíaHospital Cayetano HerediaLimaPerú
| | - Ana Cecilia Gonzales-Luna
- Unidad de Arritmias, Clínica Delgado. Lima, Perú.Unidad de ArritmiasClínica DelgadoLimaPerú
- . Unidad de Arritmias, Hospital Edgardo Rebagliati. Lima, Perú.Unidad de ArritmiasHospital Edgardo RebagliatiLimaPerú
| | - Mario Cabrera-Saldaña
- Unidad de Arritmias, Clínica Delgado. Lima, Perú.Unidad de ArritmiasClínica DelgadoLimaPerú
- . Unidad de Arritmias, Servicio de Cardiología Invasiva, Instituto Nacional Cardiovascular - INCOR EsSalud. Lima, Perú.Unidad de ArritmiasServicio de Cardiología InvasivaInstituto Nacional Cardiovascular - INCOR EsSaludLimaPerú
| | - Pablo Mendoza-Novoa
- Unidad de Arritmias, Clínica Delgado. Lima, Perú.Unidad de ArritmiasClínica DelgadoLimaPerú
- . Unidad de Arritmias, Hospital del Niño. Lima, Perú.Unidad de ArritmiasHospital del NiñoLimaPerú
| | - Paula Solórzano-Altamirano
- . Unidad de Docencia en Arritmias, APSA-QRS VITAL. Lima, Perú.Unidad de Docencia en ArritmiasAPSA-QRS VITALLimaPerú
| | - Milton Guevara-Valdivia
- . Departamento de Electrofisiología Cardiaca, Unidad Médica de Alta Especialidad del Hospital de Especialidades Dr. Antonio Fraga Mouret, Centro Médico Nacional La Raza, Instituto Mexicano del Seguro Social. Ciudad de México, México.Instituto Mexicano del Seguro SocialDepartamento de Electrofisiología Cardiaca, Unidad Médica de Alta Especialidad del Hospital de Especialidades Dr. Antonio Fraga MouretCentro Médico Nacional La RazaInstituto Mexicano del Seguro SocialCiudad de MéxicoMexico
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23
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Monfort A, Rivas A, Banydeen R, Inamo J, Farid K, Neviere R. Pulmonary 99mTc-HMDP uptake correlates with restrictive ventilatory defects and abnormal lung reactance in transthyretin cardiac amyloidosis patients. Respir Res 2022; 23:72. [PMID: 35346209 PMCID: PMC8962108 DOI: 10.1186/s12931-022-01995-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 03/15/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Pulmonary involvement in individuals with transthyretin cardiac amyloidosis is unclear. The aim of this study was to quantify 99mTc-hydroxy methylene diphosphonate (HMDP) lung retention in hereditary transthyretin (ATTRv) cardiac amyloidosis patients and to relate tracer uptake intensity to pulmonary function and aerobic capacity. METHODS We prospectively enrolled 20 patients with biopsy-proven ATTRv cardiac amyloidosis and 20 control subjects. Cardiac involvement was confirmed by echocardiography and nuclear imaging using 99mTc-HMDP. Semi-quantitative analysis of the heart, rib and lung retention was assessed using a simple region of interest technique. Pulmonary function was evaluation by the means of whole-body plethysmography, diffusing capacity of the lung for carbon monoxide, forced oscillation technique and cardiopulmonary exercise testing. RESULTS Pulmonary tracer uptake estimated by lung to rib retention ratio was higher in ATTRv amyloidosis patients compared with control subjects: median 0.62 (0.55-0.69) vs 0.51 (0.46-0.60); p = 0.014. Analysis of relation between lung 99mTc-HMDP retention and pulmonary function parameters shown statistically significant correlations with total lung volume (% predicted), lung reactance (Xrs 5 Hz) and peak VO2, suggesting total lung capacity restriction impaired elastic properties of the lung and poor aerobic capacity. CONCLUSION Our study suggests that some grade of pulmonary retention of 99mTc-HMDP may occur in patients with cardiac ATTRv amyloidosis, which can elicit deleterious effects on patient's lung function and aerobic capacity.
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Affiliation(s)
- Astrid Monfort
- Department of Cardiology, CHU Martinique (University Hospital of Martinique), 97200, Fort-de-France, France
- Cardiovascular Research Team EA7525, Université des Antilles (University of the French West Indies), 97200, Fort-de-France, France
| | - Alexia Rivas
- Department of Nuclear Medicine, CHU Martinique (University Hospital of Martinique), 97200, Fort-de-France, France
| | - Rishika Banydeen
- Department of Clinical Research, CHU Martinique (University Hospital of Martinique), 97200, Fort-de-France, France
- Cardiovascular Research Team EA7525, Université des Antilles (University of the French West Indies), 97200, Fort-de-France, France
| | - Jocelyn Inamo
- Department of Cardiology, CHU Martinique (University Hospital of Martinique), 97200, Fort-de-France, France
- Cardiovascular Research Team EA7525, Université des Antilles (University of the French West Indies), 97200, Fort-de-France, France
| | - Karim Farid
- Department of Nuclear Medicine, CHU Martinique (University Hospital of Martinique), 97200, Fort-de-France, France
- INSERM U1144, Université de Paris, 75006, Paris, France
| | - Remi Neviere
- Department of Cardiology, CHU Martinique (University Hospital of Martinique), 97200, Fort-de-France, France.
- Cardiovascular Research Team EA7525, Université des Antilles (University of the French West Indies), 97200, Fort-de-France, France.
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24
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The roles of global longitudinal strain imaging in contemporary clinical cardiology. J Med Ultrason (2001) 2022; 49:175-185. [PMID: 35088169 DOI: 10.1007/s10396-021-01184-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Accepted: 11/11/2021] [Indexed: 12/26/2022]
Abstract
Myocardial deformation imaging is now readily available during routine echocardiography and plays an important role in the advanced care of cardiovascular diseases. Its clinical value in detecting subtle myocardial dysfunction, by helping diagnose disease and allowing prediction of disease progression and earlier pharmacological intervention, has been demonstrated. Strain imaging has been the most studied and clinically used technique in the field of cardio-oncology. A relative percent reduction in left ventricular (LV) global longitudinal strain > 15% from baseline is considered a marker of early subclinical LV dysfunction and may have the potential to guide early initiation of cardioprotective therapy. The role of strain imaging is expanding to other fields, such as cardiac amyloidosis, other cardiomyopathies, valvular heart diseases, pulmonary hypertension, and heart failure with preserved ejection fraction. It is also used for the evaluation of the right ventricle and atria. This review aims to provide a current understanding of the roles of strain imaging in the evaluation and management of patients with cardiovascular diseases in clinical practice.
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25
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Banydeen R, Vergaro G, Deney A, Monfort A, Emdin M, Lairez O, Giguet AG, Inamo J, Neviere R. Restrictive spirometry pattern and abnormal cardiopulmonary response to exercise in transthyretin cardiac amyloidosis. Eur Respir J 2022; 59:13993003.02838-2021. [PMID: 34996829 DOI: 10.1183/13993003.02838-2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 12/09/2021] [Indexed: 11/05/2022]
Affiliation(s)
- Rishika Banydeen
- Department of Clinical Research, CHU Martinique (University Hospital of Martinique), Fort de France, France.,Cardiovascular Research Team EA7525, Université des Antilles (University of the French West Indies), Fort de France, France
| | - Giuseppe Vergaro
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa and Division of Cardiology and Cardiovascular Medicine, Fondazione Toscana Gabriele Monasterio, Pisa
| | - Antoine Deney
- Department of Cardiology, Rangueil Hospital, CHU Toulouse (University Hospital of Toulouse), Toulouse, France
| | - Astrid Monfort
- Cardiovascular Research Team EA7525, Université des Antilles (University of the French West Indies), Fort de France, France.,Department of Cardiology, CHU Martinique (University Hospital of Martinique), Fort de France, France
| | - Michele Emdin
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa and Division of Cardiology and Cardiovascular Medicine, Fondazione Toscana Gabriele Monasterio, Pisa
| | - Olivier Lairez
- Department of Cardiology, Rangueil Hospital, CHU Toulouse (University Hospital of Toulouse), Toulouse, France
| | - Anna Gaelle Giguet
- Neuromuscular and Neurological Disease Reference Center (CeRCa), CHU Martinique (University Hospital of Martinique), Fort de France, France
| | - Jocelyn Inamo
- Cardiovascular Research Team EA7525, Université des Antilles (University of the French West Indies), Fort de France, France.,Department of Cardiology, CHU Martinique (University Hospital of Martinique), Fort de France, France
| | - Remi Neviere
- Cardiovascular Research Team EA7525, Université des Antilles (University of the French West Indies), Fort de France, France .,Department of Cardiology, CHU Martinique (University Hospital of Martinique), Fort de France, France
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26
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Rubinstein SM, Stockerl-Goldstein K. How to Screen for Monoclonal Gammopathy in Patients With a Suspected Amyloidosis. JACC CardioOncol 2021; 3:590-593. [PMID: 34729532 PMCID: PMC8543087 DOI: 10.1016/j.jaccao.2021.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 06/30/2021] [Accepted: 07/05/2021] [Indexed: 11/16/2022] Open
Affiliation(s)
- Samuel M Rubinstein
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, North Carolina, USA
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Fischer K, Lellouche N, Damy T, Martins R, Clementy N, Bisson A, Lesaffre F, Espinosa M, Garcia R, Degand B, Serzian G, Jourda F, Huttin O, Guichard JB, Devilliers H, Eicher JC, Laurent G, Guenancia C. Cardiovascular outcomes after cardiac resynchronization therapy in cardiac amyloidosis. ESC Heart Fail 2021; 9:740-750. [PMID: 34734471 PMCID: PMC8787999 DOI: 10.1002/ehf2.13663] [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: 04/27/2021] [Revised: 09/08/2021] [Accepted: 10/04/2021] [Indexed: 12/03/2022] Open
Abstract
Aims Cardiac resynchronization therapy (CRT) is highly effective in dilated cardiomyopathy (DCM) patients with impaired left ventricular ejection fraction (LVEF) and left bundle block branch. In cardiac amyloidosis (CA) patients, left ventricular dysfunction and conduction defects are common, but the potential of CRT to improve cardiac remodelling and survival in this particular setting remains undefined. We investigated cardiovascular outcomes in CA patients after CRT implantation in terms of CRT echocardiographic response and major cardiovascular events (MACEs). Methods and results Our retrospective study included 47 CA patients implanted with CRT devices from January 2012 to February 2020, in nine French university hospitals (77 ± 6 years old, baseline LVEF 30 ± 8%) compared with propensity‐matched (1:1 for age, LVEF at implantation, and CRT indication) DCM patients with a CRT device. CA patients had lower rates of CRT response (absolute delta LVEF ≥ 10%) compared with DCM patients (36% vs. 70%, P = 0.002). After multivariate Cox analysis, CA was independently associated with MACE (hospitalization for heart failure/cardiovascular death) [hazard ratio (HR) 3.73, 95% confidence interval (CI) 1.85–7.54, P < 0.001], along with the absence of CRT response (HR 3.01, 95% CI 1.56–5.79, P = 0.001). The presence of echocardiographic CRT response (absolute delta LVEF ≥ 10%) was the only predictive factor of MACE‐free survival in CA patients (HR 0.36, 95% CI 0.15–0.86, P = 0.002). Conclusion Compared with a matched cohort of DCM patients, CA patients had a lower rate of CRT response and consequently a worse cardiovascular prognosis after CRT implantation. However, CRT could be beneficial even in CA patients given that CRT response was associated with better cardiac outcomes in this population.
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Affiliation(s)
- Kilian Fischer
- Department of Cardiology, Dijon University Hospital, 14 rue Paul Gaffarel, Dijon, 21079, France
| | - Nicolas Lellouche
- Department of Cardiology, Referral Center for Cardiac Amyloidosis, GRC Amyloid Research Institute, DHU-ATVB, Inserm U955, University Hospital Henri Mondor, Créteil, France
| | - Thibaud Damy
- Department of Cardiology, Referral Center for Cardiac Amyloidosis, GRC Amyloid Research Institute, DHU-ATVB, Inserm U955, University Hospital Henri Mondor, Créteil, France
| | - Raphaël Martins
- Department of Cardiology, Pontchaillou Hospital, Rennes, France
| | - Nicolas Clementy
- Department of Cardiology, Tours University Hospital, Tours, France
| | - Arnaud Bisson
- Department of Cardiology, Tours University Hospital, Tours, France
| | | | | | - Rodrigue Garcia
- Department of Cardiology, Poitiers University Hospital, Poitiers, France
| | - Bruno Degand
- Department of Cardiology, Poitiers University Hospital, Poitiers, France
| | - Guillaume Serzian
- Department of Cardiology, Regional University Hospital Jean Minjoz, Besançon, France
| | | | - Olivier Huttin
- Department of Cardiology, Nancy University Hospital, Nancy, France
| | | | | | - Jean-Christophe Eicher
- Department of Cardiology, Dijon University Hospital, 14 rue Paul Gaffarel, Dijon, 21079, France
| | - Gabriel Laurent
- Department of Cardiology, Dijon University Hospital, 14 rue Paul Gaffarel, Dijon, 21079, France
| | - Charles Guenancia
- Department of Cardiology, Dijon University Hospital, 14 rue Paul Gaffarel, Dijon, 21079, France.,EA 7460, University of Burgundy, Dijon, France
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28
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Grogan M, Lopez-Jimenez F, Cohen-Shelly M, Dispenzieri A, Attia ZI, Abou Ezzedine OF, Lin G, Kapa S, Borgeson DD, Friedman PA, Murphree DH. Artificial Intelligence-Enhanced Electrocardiogram for the Early Detection of Cardiac Amyloidosis. Mayo Clin Proc 2021; 96:2768-2778. [PMID: 34218880 DOI: 10.1016/j.mayocp.2021.04.023] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Accepted: 04/23/2021] [Indexed: 01/14/2023]
Abstract
OBJECTIVE To develop an artificial intelligence (AI)-based tool to detect cardiac amyloidosis (CA) from a standard 12-lead electrocardiogram (ECG). METHODS We collected 12-lead ECG data from 2541 patients with light chain or transthyretin CA seen at Mayo Clinic between 2000 and 2019. Cases were nearest neighbor matched for age and sex, with 2454 controls. A subset of 2997 (60%) cases and controls were used to train a deep neural network to predict the presence of CA with an internal validation set (n=999; 20%) and a randomly selected holdout testing set (n=999; 20%). We performed experiments using single-lead and 6-lead ECG subsets. RESULTS The area under the receiver operating characteristic curve (AUC) was 0.91 (CI, 0.90 to 0.93), with a positive predictive value for detecting either type of CA of 0.86. By use of a cutoff probability of 0.485 determined by the Youden index, 426 (84%) of the holdout patients with CA were detected by the model. Of the patients with CA and prediagnosis electrocardiographic studies, the AI model successfully predicted the presence of CA more than 6 months before the clinical diagnosis in 59%. The best single-lead model was V5 with an AUC of 0.86 and a precision of 0.78, with other single leads performing similarly. The 6-lead (bipolar leads) model had an AUC of 0.90 and a precision of 0.85. CONCLUSION An AI-driven ECG model effectively detects CA and may promote early diagnosis of this life-threatening disease.
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Affiliation(s)
- Martha Grogan
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN.
| | | | | | - Angela Dispenzieri
- Division of Hematology, Department of Medicine, Mayo Clinic, Rochester, MN; Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN
| | - Zachi I Attia
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | | | - Grace Lin
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | - Suraj Kapa
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
| | | | - Paul A Friedman
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN
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Abstract
The number of therapies for heart failure (HF) with reduced ejection fraction has nearly doubled in the past decade. In addition, new therapies for HF caused by hypertrophic and infiltrative disease are emerging rapidly. Indeed, we are on the verge of a new era in HF in which insights into the biology of myocardial disease can be matched to an understanding of the genetic predisposition in an individual patient to inform precision approaches to therapy. In this Review, we summarize the biology of HF, emphasizing the causal relationships between genetic contributors and traditional structure-based remodelling outcomes, and highlight the mechanisms of action of traditional and novel therapeutics. We discuss the latest advances in our understanding of both the Mendelian genetics of cardiomyopathy and the complex genetics of the clinical syndrome presenting as HF. In the phenotypic domain, we discuss applications of machine learning for the subcategorization of HF in ways that might inform rational prescribing of medications. We aim to bridge the gap between the biology of the failing heart, its diverse clinical presentations and the range of medications that we can now use to treat it. We present a roadmap for the future of precision medicine in HF.
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30
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Bonelli A, Paris S, Nardi M, Henein MY, Agricola E, Troise G, Faggiano P. Aortic Valve Stenosis and Cardiac Amyloidosis: A Misleading Association. J Clin Med 2021; 10:4234. [PMID: 34575344 PMCID: PMC8471197 DOI: 10.3390/jcm10184234] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 09/13/2021] [Accepted: 09/13/2021] [Indexed: 01/15/2023] Open
Abstract
The association between aortic stenosis (AS) and cardiac amyloidosis (CA) is more frequent than expected. Albeit rare, CA, particularly the transthyretin (ATTR) form, is commonly found in elderly people. ATTR-CA is also the most prevalent form in patients with AS. These conditions share pathophysiological, clinical and imaging findings, making the diagnostic process very challenging. To date, a multiparametric evaluation is suggested in order to detect patients with both AS and CA and choose the best therapeutic option. Given the accuracy of modern non-invasive techniques (i.e., bone scintigraphy), early diagnosis of CA is possible. Flow-charts with the main CA findings which may help clinicians in the diagnostic process have been proposed. The prognostic impact of the combination of AS and CA is not fully known; however, new available specific treatments of ATTR-CA have changed the natural history of the disease and have some impact on the decision-making process for the management of AS. Hence the relevance of detecting these two conditions when simultaneously present. The specific features helping the detection of AS-CA association are discussed in this review, focusing on the shared pathophysiological characteristics and the common clinical and imaging hallmarks.
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Affiliation(s)
- Andrea Bonelli
- Cardiology Unit, Spedali Civili and University of Brescia, 25100 Brescia, Italy; (A.B.); (S.P.); (M.N.)
| | - Sara Paris
- Cardiology Unit, Spedali Civili and University of Brescia, 25100 Brescia, Italy; (A.B.); (S.P.); (M.N.)
| | - Matilde Nardi
- Cardiology Unit, Spedali Civili and University of Brescia, 25100 Brescia, Italy; (A.B.); (S.P.); (M.N.)
| | - Michael Y. Henein
- Department of Public Health and Clinical Medicine, Umea University, 90187 Umea, Sweden;
| | - Eustachio Agricola
- Cardiovascular Imaging Unit, Cardio-Thoracic-Vascular Department, San Raffaele Hospital, Vita-Salute University, 20132 Milan, Italy;
| | - Giovanni Troise
- Cardiac Surgery, Cardiothoracic Department, Fondazione Poliambulanza, 25100 Brescia, Italy;
| | - Pompilio Faggiano
- Cardiology, Cardiothoracic Department, Fondazione Poliambulanza, 25100 Brescia, Italy
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31
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Simões MV, Fernandes F, Marcondes-Braga FG, Scheinberg P, Correia EDB, Rohde LEP, Bacal F, Alves SMM, Mangini S, Biolo A, Beck-da-Silva L, Szor RS, Marques W, Oliveira ASB, Cruz MW, Bueno BVK, Hajjar LA, Issa AFC, Ramires FJA, Coelho OR, Schmidt A, Pinto IMF, Rochitte CE, Vieira MLC, Mesquita CT, Ramos CD, Soares-Junior J, Romano MMD, Mathias W, Garcia MI, Montera MW, de Melo MDT, Silva SME, Garibaldi PMM, de Alencar AC, Lopes RD, de Ávila DX, Viana D, Saraiva JFK, Canesin MF, de Oliveira GMM, Mesquita ET. Position Statement on Diagnosis and Treatment of Cardiac Amyloidosis - 2021. Arq Bras Cardiol 2021; 117:561-598. [PMID: 34550244 PMCID: PMC8462947 DOI: 10.36660/abc.20210718] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- Marcus V. Simões
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoRibeirão PretoBrasilFaculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto – Brasil
| | - Fabio Fernandes
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
| | - Fabiana G. Marcondes-Braga
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
| | - Philip Scheinberg
- Hospital da Beneficência Portuguesa de São PauloSão PauloSPBrasilHospital da Beneficência Portuguesa de São Paulo, São Paulo, SP – Brasil
| | - Edileide de Barros Correia
- Instituto Dante Pazzanese de CardiologiaSão PauloSPBrasilInstituto Dante Pazzanese de Cardiologia, São Paulo, SP – Brasil
| | - Luis Eduardo P. Rohde
- Hospital de Clínicas de Porto AlegrePorto AlegreRSBrasilHospital de Clínicas de Porto Alegre, Porto Alegre, RS – Brasil
- Hospital Moinhos de VentoPorto AlegreRSBrasilHospital Moinhos de Vento, Porto Alegre, RS – Brasil
- Universidade Federal do Rio Grande do SulPorto AlegreRSBrasilUniversidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS – Brasil
| | - Fernando Bacal
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
| | - Silvia Marinho Martins Alves
- Pronto Socorro Cardiológico de PernambucoRecifePEBrasilPronto Socorro Cardiológico de Pernambuco (PROCAPE), Recife, PE – Brasil
- Universidade de PernambucoRecifePEBrasilUniversidade de Pernambuco (UPE), Recife, PE – Brasil
| | - Sandrigo Mangini
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
| | - Andréia Biolo
- Hospital de Clínicas de Porto AlegrePorto AlegreRSBrasilHospital de Clínicas de Porto Alegre, Porto Alegre, RS – Brasil
| | - Luis Beck-da-Silva
- Hospital de Clínicas de Porto AlegrePorto AlegreRSBrasilHospital de Clínicas de Porto Alegre, Porto Alegre, RS – Brasil
- Universidade Federal do Rio Grande do SulPorto AlegreRSBrasilUniversidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, RS – Brasil
| | - Roberta Shcolnik Szor
- Fundação Faculdade de MedicinaSão PauloSPBrasilFundação Faculdade de Medicina, São Paulo, SP – Brasil
- Universidade de São PauloSão PauloSPBrasilInstituto do Câncer do Estado de São Paulo da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP – Brasil
| | - Wilson Marques
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoRibeirão PretoBrasilFaculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto – Brasil
| | - Acary Souza Bulle Oliveira
- Universidade Federal de São PauloSão PauloSPBrasilUniversidade Federal de São Paulo, São Paulo, SP – Brasil
| | - Márcia Waddington Cruz
- Universidade Federal do Rio de JaneiroRio de JaneiroRJBrasilHospital Universitário Clementino Fraga Filho (HUCFF) da Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ – Brasil
| | - Bruno Vaz Kerges Bueno
- Faculdade de Ciências Médicas da Santa Casa de São PauloSão PauloSPBrasilFaculdade de Ciências Médicas da Santa Casa de São Paulo, São Paulo, SP – Brasil
| | - Ludhmila Abrahão Hajjar
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
- Universidade de São PauloSão PauloSPBrasilInstituto do Câncer do Estado de São Paulo da Faculdade de Medicina da Universidade de São Paulo, São Paulo, SP – Brasil
| | - Aurora Felice Castro Issa
- Instituto Nacional de CardiologiaRio de JaneiroRJBrasilInstituto Nacional de Cardiologia, Rio de Janeiro, RJ – Brasil
| | - Felix José Alvarez Ramires
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
- Hospital Israelita Albert EinsteinSão PauloSPBrasilHospital Israelita Albert Einstein, São Paulo, SP – Brasil
| | - Otavio Rizzi Coelho
- Universidade Estadual de CampinasCampinasSPBrasilFaculdade de Ciências Médicas da Universidade Estadual de Campinas (UNICAMP), Campinas, SP – Brasil
| | - André Schmidt
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoRibeirão PretoBrasilFaculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto – Brasil
| | | | - Carlos Eduardo Rochitte
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
- Hospital do CoraçãoSão PauloSPBrasilHospital do Coração (HCor), São Paulo, SP – Brasil
- Hospital Pró-CardíacoRio de JaneiroRJBrasilHospital Pró-Cardíaco, Rio de Janeiro, RJ – Brasil
| | - Marcelo Luiz Campos Vieira
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
- Hospital Israelita Albert EinsteinSão PauloSPBrasilHospital Israelita Albert Einstein, São Paulo, SP – Brasil
| | - Cláudio Tinoco Mesquita
- Universidade Federal FluminenseRio de JaneiroRJBrasilUniversidade Federal Fluminense (UFF), Rio de Janeiro, RJ – Brasil
| | - Celso Dario Ramos
- Universidade Estadual de CampinasCampinasSPBrasilFaculdade de Ciências Médicas da Universidade Estadual de Campinas (UNICAMP), Campinas, SP – Brasil
| | - José Soares-Junior
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
| | - Minna Moreira Dias Romano
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoRibeirão PretoBrasilFaculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto – Brasil
| | - Wilson Mathias
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoRibeirão PretoBrasilFaculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto – Brasil
| | - Marcelo Iório Garcia
- Universidade Federal do Rio de JaneiroRio de JaneiroRJBrasilHospital Universitário Clementino Fraga Filho (HUCFF) da Universidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ – Brasil
| | | | | | | | - Pedro Manoel Marques Garibaldi
- Universidade de São PauloFaculdade de Medicina de Ribeirão PretoRibeirão PretoBrasilFaculdade de Medicina de Ribeirão Preto da Universidade de São Paulo, Ribeirão Preto – Brasil
| | - Aristóteles Comte de Alencar
- Universidade de São PauloHospital das Clínicas da Faculdade de MedicinaInstituto do CoraçãoSão PauloSPBrasilInstituto do Coração (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP – Brasil
| | | | - Diane Xavier de Ávila
- Hospital Pró-CardíacoRio de JaneiroRJBrasilHospital Pró-Cardíaco, Rio de Janeiro, RJ – Brasil
- Complexo Hospitalar de NiteróiRio de JaneiroRJBrasilComplexo Hospitalar de Niterói, Rio de Janeiro, RJ – Brasil
- Hospital e Maternidade Christóvão da GamaSanto AndréSPBrasilHospital e Maternidade Christóvão da Gama, Santo André, SP – Brasil
- Hospital Universitário Antônio PedroRio de JaneiroRJBrasilHospital Universitário Antônio Pedro (Huap), Rio de Janeiro, RJ – Brasil
| | - Denizar Viana
- Universidade do Estado do Rio de JaneiroRio de JaneiroRJBrasilUniversidade do Estado do Rio de Janeiro, Rio de Janeiro, RJ – Brasil
| | - José Francisco Kerr Saraiva
- Sociedade Campineira de Educação e InstruçãoCampinasSPBrasilSociedade Campineira de Educação e Instrução, Campinas, SP – Brasil
| | - Manoel Fernandes Canesin
- Universidade Estadual de LondrinaLondrinaPRBrasilHospital Universitário da Universidade Estadual de Londrina, Londrina, PR – Brasil
| | - Glaucia Maria Moraes de Oliveira
- Universidade Federal do Rio de JaneiroRio de JaneiroRJBrasilUniversidade Federal do Rio de Janeiro (UFRJ), Rio de Janeiro, RJ – Brasil
| | - Evandro Tinoco Mesquita
- Universidade Federal FluminenseRio de JaneiroRJBrasilUniversidade Federal Fluminense (UFF), Rio de Janeiro, RJ – Brasil
- Centro de Ensino e Treinamento Edson de Godoy BuenoRio de JaneiroRJBrasilCentro de Ensino e Treinamento Edson de Godoy Bueno/UHG, Rio de Janeiro, RJ – Brasil
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Agha AM, Palaskas N, Patel AR, DeCara J, Parwani P, Iliescu C, Durand JB, Kim P, Hassan S, Gladish G, Lee HC, Kaufman GP, Lopez-Mattei JC. Cardiac Magnetic Resonance Predicting Outcomes Among Patients at Risk for Cardiac AL Amyloidosis. Front Cardiovasc Med 2021; 8:626414. [PMID: 34268341 PMCID: PMC8276072 DOI: 10.3389/fcvm.2021.626414] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 04/29/2021] [Indexed: 11/22/2022] Open
Abstract
Introduction: Patients with systemic AL amyloidosis (AL) should be evaluated for cardiac amyloidosis (CA), as prognosis is strongly related to cardiac involvement. We assessed the characteristics of patients referred to cardiac magnetic resonance (CMR) with suspected CA from a cancer center and determine predictors of mortality/heart failure hospitalizations (HFH). Methods: Forty-four consecutive patients referred for CMR with suspected CA were retrospectively included. Variables collected included cardiac biomarkers, in addition to echocardiographic and CMR variables. Survival analyses were performed to determine which variables were more predictive of mortality and HFH. Results: Of the 44 patients included, 55% were females. 73% of patients were diagnosed with CA by CMR; 56% of them had an established diagnosis of AL. Patients with CA by CMR had higher native T1, higher extracellular volume (ECV) fraction, higher T2, less negative GLS by Echo, and higher troponin I and B-type natriuretic peptide (BNP). Kaplan-Meier survival analysis revealed that the following were predictive of mortality: an ECV ≥ 0.50 (p = 0.0098), CMR LVEF < 50% (p = 0.0010), T2/ECV ≤ 100 (p = 0.0001), and troponin I > 0.03 (p = 0.0025). In a stepwise conditional Cox logistic regression model, the only variable predictive of a composite of mortality and HFH was ECV (HR: 1.17, 95% CI = 1.02–1.34 p = 0.030). Conclusion: ECV seems to be an important biomarker that could be a predictor of outcomes in cardiac AL amyloidosis. In combination, CMR and serum cardiac biomarkers might help to establish prognosis in patients with CA.
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Affiliation(s)
- Ali M Agha
- Department of Medicine and Center for Cardiometabolic Disease Prevention, Baylor College of Medicine, Houston, TX, United States
| | - Nicolas Palaskas
- Division of Internal Medicine, Department Cardiology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Amit R Patel
- Cardiology Section, Department of Medicine, University of Chicago, Chicago, IL, United States
| | - Jeanne DeCara
- Cardiology Section, Department of Medicine, University of Chicago, Chicago, IL, United States
| | - Purvi Parwani
- Division of Cardiology, Department of Medicine, Loma Linda University Health, Loma Linda, CA, United States
| | - Cezar Iliescu
- Division of Internal Medicine, Department Cardiology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Jean B Durand
- Division of Internal Medicine, Department Cardiology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Peter Kim
- Division of Internal Medicine, Department Cardiology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Saamir Hassan
- Division of Internal Medicine, Department Cardiology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Gregory Gladish
- Division of Diagnostic Imaging, Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Hans C Lee
- Division of Cancer Medicine, Department of Lymphoma and Myeloma, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Gregory P Kaufman
- Division of Cancer Medicine, Department of Lymphoma and Myeloma, University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Juan C Lopez-Mattei
- Division of Internal Medicine, Department Cardiology, University of Texas MD Anderson Cancer Center, Houston, TX, United States.,Division of Diagnostic Imaging, Department of Diagnostic Radiology, University of Texas MD Anderson Cancer Center, Houston, TX, United States
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33
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Kozak S, Ulbrich K, Migacz M, Szydło K, Mizia-Stec K, Holecki M. Cardiac Amyloidosis-Challenging Diagnosis and Unclear Clinical Picture. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:medicina57050450. [PMID: 34066321 PMCID: PMC8148212 DOI: 10.3390/medicina57050450] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 04/24/2021] [Accepted: 05/04/2021] [Indexed: 02/05/2023]
Abstract
Cardiac amyloidosis (CA) is a rare systemic disease determined by the extracellular deposition of amyloid protein in the heart. The protein can accumulate in any part of the heart: myocardium, vessels, endocardium, valves, epicardium and parietal pericardium. The types of CA include the following types: light chain (AL), amyloidosis AA (Amyloid A) and transthyretin (ATTR). The detection of specific subtypes remains of great importance to implement the targeted treatment. We present the case of a 65-year-old woman, who was admitted with severe deterioration of exercise capacity, a bilateral reduction of physiological vesicular murmur, ascites and edema of lower extremities. CA was suspected due to echocardiographic examination results, which led to further examination and final diagnosis. The aim of this study is to improve the disease awareness among clinicians and shorten the delay between the first symptoms and the diagnosis establishment resulting in a better outcome.
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Affiliation(s)
- Sylwia Kozak
- Student Scientific Society at the Department of Internal, Autoimmune and Metabolic Diseases, School of Medicine, Medical University of Silesia, 40-752 Katowice, Poland; (S.K.); (K.U.)
| | - Krzysztof Ulbrich
- Student Scientific Society at the Department of Internal, Autoimmune and Metabolic Diseases, School of Medicine, Medical University of Silesia, 40-752 Katowice, Poland; (S.K.); (K.U.)
| | - Maciej Migacz
- Department of Internal, Autoimmune and Metabolic Diseases, School of Medicine, Medical University of Silesia, 40-752 Katowice, Poland;
| | - Krzysztof Szydło
- 1st Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, 40-752 Katowice, Poland; (K.S.); (K.M.-S.)
| | - Katarzyna Mizia-Stec
- 1st Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, 40-752 Katowice, Poland; (K.S.); (K.M.-S.)
| | - Michał Holecki
- Department of Internal, Autoimmune and Metabolic Diseases, School of Medicine, Medical University of Silesia, 40-752 Katowice, Poland;
- Correspondence: ; Tel.: +48-32-7894301
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Nitsche C, Scully PR, Patel KP, Kammerlander AA, Koschutnik M, Dona C, Wollenweber T, Ahmed N, Thornton GD, Kelion AD, Sabharwal N, Newton JD, Ozkor M, Kennon S, Mullen M, Lloyd G, Fontana M, Hawkins PN, Pugliese F, Menezes LJ, Moon JC, Mascherbauer J, Treibel TA. Prevalence and Outcomes of Concomitant Aortic Stenosis and Cardiac Amyloidosis. J Am Coll Cardiol 2021; 77:128-139. [PMID: 33181246 PMCID: PMC7805267 DOI: 10.1016/j.jacc.2020.11.006] [Citation(s) in RCA: 186] [Impact Index Per Article: 62.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 10/26/2020] [Accepted: 11/04/2020] [Indexed: 01/15/2023]
Abstract
BACKGROUND Older patients with severe aortic stenosis (AS) are increasingly identified as having cardiac amyloidosis (CA). It is unknown whether concomitant AS-CA has worse outcomes or results in futility of transcatheter aortic valve replacement (TAVR). OBJECTIVES This study identified clinical characteristics and outcomes of AS-CA compared with lone AS. METHODS Patients who were referred for TAVR at 3 international sites underwent blinded research core laboratory 99mtechnetium-3,3-diphosphono-1,2-propanodicarboxylic acid (DPD) bone scintigraphy (Perugini grade 0: negative; grades 1 to 3: increasingly positive) before intervention. Transthyretin-CA (ATTR) was diagnosed by DPD and absence of a clonal immunoglobulin, and light-chain CA (AL) was diagnosed via tissue biopsy. National registries captured all-cause mortality. RESULTS A total of 407 patients (age 83.4 ± 6.5 years; 49.8% men) were recruited. DPD was positive in 48 patients (11.8%; grade 1: 3.9% [n = 16]; grade 2/3: 7.9% [n = 32]). AL was diagnosed in 1 patient with grade 1. Patients with grade 2/3 had worse functional capacity, biomarkers (N-terminal pro-brain natriuretic peptide and/or high-sensitivity troponin T), and biventricular remodeling. A clinical score (RAISE) that used left ventricular remodeling (hypertrophy/diastolic dysfunction), age, injury (high-sensitivity troponin T), systemic involvement, and electrical abnormalities (right bundle branch block/low voltages) was developed to predict the presence of AS-CA (area under the curve: 0.86; 95% confidence interval: 0.78 to 0.94; p < 0.001). Decisions by the heart team (DPD-blinded) resulted in TAVR (333 [81.6%]), surgical AVR (10 [2.5%]), or medical management (65 [15.9%]). After a median of 1.7 years, 23% of patients died. One-year mortality was worse in all patients with AS-CA (grade: 1 to 3) than those with lone AS (24.5% vs. 13.9%; p = 0.05). TAVR improved survival versus medical management; AS-CA survival post-TAVR did not differ from lone AS (p = 0.36). CONCLUSIONS Concomitant pathology of AS-CA is common in older patients with AS and can be predicted clinically. AS-CA has worse clinical presentation and a trend toward worse prognosis, unless treated. Therefore, TAVR should not be withheld in AS-CA.
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Affiliation(s)
- Christian Nitsche
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Paul R Scully
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Cardiology Department, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - Kush P Patel
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Andreas A Kammerlander
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Matthias Koschutnik
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Carolina Dona
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Tim Wollenweber
- Department of Nuclear Medicine, Medical University of Vienna, Vienna, Austria
| | - Nida Ahmed
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - George D Thornton
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | | | | | | | - Muhiddin Ozkor
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Simon Kennon
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Michael Mullen
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Guy Lloyd
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; Queen Mary University London, London, United Kingdom
| | | | | | - Francesca Pugliese
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Queen Mary University London, London, United Kingdom
| | - Leon J Menezes
- Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom; UCL/ULCH NIHR Biomedical Research Centre, London, United Kingdom
| | - James C Moon
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom
| | - Julia Mascherbauer
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Thomas A Treibel
- Institute of Cardiovascular Science, University College London, London, United Kingdom; Barts Heart Centre, St. Bartholomew's Hospital, London, United Kingdom.
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35
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A serine protease secreted from Bacillus subtilis cleaves human plasma transthyretin to generate an amyloidogenic fragment. Commun Biol 2020; 3:764. [PMID: 33311636 PMCID: PMC7733459 DOI: 10.1038/s42003-020-01493-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 11/16/2020] [Indexed: 12/14/2022] Open
Abstract
Aggregation of human wild-type transthyretin (hTTR), a homo-tetrameric plasma protein, leads to acquired senile systemic amyloidosis (SSA), recently recognised as a major cause of cardiomyopathies in 1-3% older adults. Fragmented hTTR is the standard composition of amyloid deposits in SSA, but the protease(s) responsible for amyloidogenic fragments generation in vivo is(are) still elusive. Here, we show that subtilisin secreted from Bacillus subtilis, a gut microbiota commensal bacterium, translocates across a simulated intestinal epithelium and cleaves hTTR both in solution and human plasma, generating the amyloidogenic fragment hTTR(59-127), which is also found in SSA amyloids in vivo. To the best of our knowledge, these findings highlight a novel pathogenic mechanism for SSA whereby increased permeability of the gut mucosa, as often occurs in elderly people, allows subtilisin (and perhaps other yet unidentified bacterial proteases) to reach the bloodstream and trigger generation of hTTR fragments, acting as seeding nuclei for preferential amyloid fibrils deposition in the heart.
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36
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Visser RAB, Gravenor C, Ahmed S, Harky A. Amyloidosis and cardiovascular diseases: A clinical insight. J Card Surg 2020; 36:522-529. [PMID: 33283354 DOI: 10.1111/jocs.15230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2020] [Accepted: 11/11/2020] [Indexed: 11/29/2022]
Abstract
Systemic amyloidosis is caused by the deposition of amyloid proteins in varying organ systems throughout the body, leading to dysfunction within those systems. The development of cardiac amyloidosis is one of the main indicators of poor prognosis in patients. Cardiac amyloidosis is most commonly caused by the immunoglobulin light chain amyloidosis and the transthyretin amyloidosis. Both have poor prognoses when associated with cardiac amyloidosis; however, the patients with the former subtype fair far worse than those with the latter. Despite amyloidosis having a history of being underdiagnosed, recent epidemiological data indicate that the rate of diagnosis has increased, which has coincided with improved in-patient median survival rates. It is of great importance that patients are diagnosed with the correct subtype as the main treatment strategy is to treat the underlying cause of amyloidosis. If a misdiagnosis is made, patients can receive treatment that might be ineffective or even harmful. A great progress has been made in pharmacological treatments for treating the underlying causes; however, many of the proposed treatments still need more evidence to support their use.
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Affiliation(s)
- Renier A B Visser
- School of Medicine, University of Central Lancashire, Preston, United Kingdom
| | - Céline Gravenor
- School of Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Sennia Ahmed
- School of Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom.,Department of Cardiac Surgery, Alder Hey Children Hospital, Liverpool, United Kingdom.,Liverpool Centre of Cardiovascular Science, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
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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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38
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Nazir T, Nuffati M. Cardiac amyloidosis-an underdiagnosed cause of heart failure in the elderly. J Saudi Heart Assoc 2020; 32:98-102. [PMID: 33154899 PMCID: PMC7640612 DOI: 10.37616/2212-5043.1016] [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: 07/17/2019] [Revised: 09/12/2019] [Accepted: 09/27/2019] [Indexed: 11/20/2022] Open
Abstract
Amyloidosis is a rare, generally multisystem disease that can also involve the heart. Infiltration of the myocardium with amyloid proteins is an important and underappreciated cause of heart failure with preserved ejection fraction in the elderly. We present the case of an 84-year-old man with chest tightness, dyspnoea, and ascites. He had a history of dyslipidaemia and ischaemic heart disease. Initial investigations showed severe diastolic dysfunction and elevated pulmonary artery systolic pressure on echocardiogram along with elevated serum natriuretic peptides. Further evaluation by a magnetic resonance imaging scan of the heart and endomyocardial biopsy confirmed the diagnosis of senile systemic amyloidosis. He made good progress after treatment with conventional heart failure drugs and is currently under consideration to start on specific medications to slow down the progression of amyloidosis. This case aims to increase clinicians' awareness of senile amyloidosis as a cause of heart failure in the elderly.
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Affiliation(s)
- Tahir Nazir
- Division of Cardiovascular Sciences, University of Manchester, Manchester, UK
| | - Mahmud Nuffati
- Cardiothoracic Centre, Royal Liverpool Hospital, Liverpool, UK
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39
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Lenihan D, Carver J, Porter C, Liu JE, Dent S, Thavendiranathan P, Mitchell JD, Nohria A, Fradley MG, Pusic I, Stockerl-Goldstein K, Blaes A, Lyon AR, Ganatra S, López-Fernández T, O’Quinn R, Minotti G, Szmit S, Cardinale D, Alvarez-Cardona J, Curigliano G, Neilan TG, Herrmann J. Cardio-oncology care in the era of the coronavirus disease 2019 (COVID-19) pandemic: An International Cardio-Oncology Society (ICOS) statement. CA Cancer J Clin 2020; 70:480-504. [PMID: 32910493 PMCID: PMC7934086 DOI: 10.3322/caac.21635] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 07/07/2020] [Accepted: 07/13/2020] [Indexed: 02/06/2023] Open
Abstract
The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has given rise to a pandemic of unprecedented proportions in the modern era because of its highly contagious nature and impact on human health and society: coronavirus disease 2019 (COVID-19). Patients with cardiovascular (CV) risk factors and established CV disease (CVD) are among those initially identified at the highest risk for serious complications, including death. Subsequent studies have pointed out that patients with cancer are also at high risk for a critical disease course. Therefore, the most vulnerable patients are seemingly those with both cancer and CVD, and a careful, unified approach in the evaluation and management of this patient population is especially needed in times of the COVID-19 pandemic. This review provides an overview of the unique implications of the viral outbreak for the field of cardio-oncology and outlines key modifications in the approach to this ever-increasing patient population. These modifications include a shift toward greater utilization of cardiac biomarkers and a more focused CV imaging approach in the broader context of modifications to typical practice pathways. The goal of this strategic adjustment is to minimize the risk of SARS-CoV-2 infection (or other future viral outbreaks) while not becoming negligent of CVD and its important impact on the overall outcomes of patients who are being treated for cancer.
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Affiliation(s)
- Daniel Lenihan
- Cardio-Oncology Center of Excellence, Washington University in St Louis, St Louis, Missouri
| | - Joseph Carver
- Division of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Charles Porter
- Cardiovascular Medicine, Cardio-Oncology Unit, University of Kansas Medical Center, Kansas City, Kansas
| | - Jennifer E. Liu
- Department of Medicine/Cardiology Service, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Susan Dent
- Department of Medicine, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Paaladinesh Thavendiranathan
- Department of Medicine, Division of Cardiology, Ted Rogers Program in Cardiotoxicity Prevention, Peter Munk Cardiac Center, University Health Network, University of Toronto, Toronto, Ontario Canada
| | - Joshua D. Mitchell
- Cardio-Oncology Center of Excellence, Washington University in St Louis, St Louis, Missouri
| | - Anju Nohria
- Cardio-Oncology Program, Brigham and Women’s Hospital and Dana Farber Cancer Institute, Harvard Medical School, Boston, Massachusetts
| | - Michael G. Fradley
- Division of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Iskra Pusic
- Division of Oncology, Washington University School of Medicine, St Louis, Missouri
| | | | - Anne Blaes
- Division of Hematology/Oncology, University of Minnesota, Minneapolis, Minnesota
| | - Alexander R. Lyon
- Cardio-Oncology Service, Royal Brompton Hospital and Imperial College London, London, United Kingdom
| | - Sarju Ganatra
- Cardio-Oncology Program, Department of Cardiovascular Medicine, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Teresa López-Fernández
- Cardiac Imaging and Cardio-Oncology Unit, Division of Cardiology, La Paz University Hospital, La Paz Hospital Institute for Health Research, Network Research Center for Cardiovascular Diseases, Madrid, Spain
| | - Rupal O’Quinn
- Division of Cardiology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Giorgio Minotti
- Department of Medicine, University Campus Bio-Medico, Rome, Italy
| | - Sebastian Szmit
- Department of Pulmonary Circulation, Thromboembolic Diseases, and Cardiology, Center of Postgraduate Medical Education, European Health Center, Otwock, Poland
| | - Daniela Cardinale
- Cardio-Oncology Unit, European Institute of Oncology, IRCCS, Milan Italy
| | - Jose Alvarez-Cardona
- Cardio-Oncology Center of Excellence, Washington University in St Louis, St Louis, Missouri
| | - Giuseppe Curigliano
- European Institute of Oncology, IRCCS, Milan Italy
- Department of Oncology and Hemato-Oncology, University of Milan, Milano, Italy
| | - Tomas G. Neilan
- Cardio-Oncology Program, Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Joerg Herrmann
- Department of Cardiovascular Disease, Mayo Clinic, Rochester, Minnesota
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40
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In Vivo Quantification of Myocardial Amyloid Deposits in Patients with Suspected Transthyretin-Related Amyloidosis (ATTR). J Clin Med 2020; 9:jcm9113446. [PMID: 33120935 PMCID: PMC7693120 DOI: 10.3390/jcm9113446] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 10/19/2020] [Accepted: 10/21/2020] [Indexed: 12/27/2022] Open
Abstract
Background: Current diagnosis of Transthyretin-related Amyloidosis (ATTR) using bone scintigraphy is primarily based on visual scoring and semi-quantitative indices. With the introduction of new potential life-prolonging drugs for ATTR, a more precise quantification of myocardial amyloid burden is desirable for improved response prediction and therapy monitoring. Methods: At first, quantification experiments using an anthropomorphic thorax phantom were performed. Second, 32 patients underwent both planar whole body [99mTc]- 3,3-Diphosphono-1,2-Propanodicarboxylic Acid (DPD)-scintigraphy and quantitative Single-Photon Emission Computed Tomography/Computed Tomography (SPECT/CT) of the thorax. SPECT/CT standardized myocardial uptake values SUVpeak and SUVpeak normalized to bone uptake (nSUVpeak) were determined. Results: Phantom measurements showed a strong linear relationship between the activity in the myocardial insert and the measured activity (r = 0.9998, p = 0.01), but the measured activity was systematically underestimated by approximately 30%. Receiver operating characteristics (ROC) analysis revealed a 100% sensitivity and specificity at a cut-off of 3.1 for SUVpeak for the differentiation of both patient groups. Conclusion: SUV quantification of ATTR amyloid burden is feasible using novel SPECT/CT technology. With a SUVpeak cut-off of 3.1, patients with Perugini grade 2 and 3 could be clearly separated from those with Perugini grade 0 and 1. Besides ATTR diagnostics, quantification of amyloid deposits could potentially be used for therapy monitoring and prognostication in patients with cardiac ATTR.
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41
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Monfort A, Banydeen R, Demoniere F, Courty B, Codiat R, Neviere R, Inamo J. Restrictive cardiac phenotype as primary cause of impaired aerobic capacity in Afro-Caribbean patients with val122ile variant transthyretin amyloid cardiomyopathy. Amyloid 2020; 27:145-152. [PMID: 32024385 DOI: 10.1080/13506129.2020.1722098] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Background: Impaired aerobic capacity in cardiac amyloidosis patients may be related to limited inotropic myocardial reserve and heart rate (HR) response limiting cardiac output rise. This study sought to investigate whether chronotropic incompetence (CI) and blunted HR recovery would be prevalent in patients with mutant transthyretin (ATTRv) cardiomyopathy.Methods and results: Eighteen ATTRv (Val122Ile) patients (72 ± 8-year) and 15 age-matched controls (73 ± 3-year) were prospectively enrolled. Patients' medical records, pulmonary function and cardiopulmonary exercise testing, including non-invasive cardiac hemodynamics and chronotropic response were studied. Compared with age-matched controls, maximal workload (91 ± 8 vs. 65 ± 20 watts) and peak VO2 (19.5 ± 3.0 vs. 14.4 ± 4.1 mL.kg-1.min-1) were lower in ATTRv patients. Despite reaching similar age-predicted maximal HR, ATTRv patients displayed smaller changes in stroke volume (SV) index relative to change in VO2 (49 ± 26 vs. 67 ± 18%). Adequate chronotropic-metabolic index was prevalent in ATTRv patients. HR recovery, as percent decrease in peak HR at 1 and 3-min, was blunded ATTv patients.Conclusions: In Val122Ile ATTRv patients, chronotropic response was appropriate relative to exercise intensity with only few patients displaying CI. HR response to exercise was further characterised by blunted HR recovery in ATTRv patients suggesting lower parasympathetic activity and greater sympathetic stimulation compared with controls.
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Affiliation(s)
- Astrid Monfort
- Department of Cardiology CHU Martinique, University Hospital of Martinique, Fort de France, France.,Cardiovascular Research Team EA7525, Antilles University, Pointe-à-Pitre, France
| | - Rishika Banydeen
- Cardiovascular Research Team EA7525, Antilles University, Pointe-à-Pitre, France.,Department of Epidemiology and Biostatistics CHU Martinique, University Hospital of Martinique, Fort de France, France
| | - Fabrice Demoniere
- Department of Cardiology CHU Martinique, University Hospital of Martinique, Fort de France, France
| | - Baptiste Courty
- Department of Cardiology CHU Martinique, University Hospital of Martinique, Fort de France, France
| | - Rebecca Codiat
- Department of Cardiology CHU Martinique, University Hospital of Martinique, Fort de France, France
| | - Remi Neviere
- Department of Cardiology CHU Martinique, University Hospital of Martinique, Fort de France, France.,Cardiovascular Research Team EA7525, Antilles University, Pointe-à-Pitre, France
| | - Jocelyn Inamo
- Department of Cardiology CHU Martinique, University Hospital of Martinique, Fort de France, France.,Cardiovascular Research Team EA7525, Antilles University, Pointe-à-Pitre, France
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42
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Lin X, Watanabe K, Kuragano M, Kurotaki Y, Nakanishi U, Tokuraku K. Dietary Intake of Rosmarinic Acid Increases Serum Inhibitory Activity in Amyloid A Aggregation and Suppresses Deposition in the Organs of Mice. Int J Mol Sci 2020; 21:E6031. [PMID: 32825797 PMCID: PMC7504104 DOI: 10.3390/ijms21176031] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Revised: 08/11/2020] [Accepted: 08/20/2020] [Indexed: 12/14/2022] Open
Abstract
Serum amyloid A (SAA) is one of the most important precursor amyloid proteins and plays a vital step in AA amyloidosis, although the underlying aggregation mechanism has not been elucidated. Since SAA aggregation is a key step in this pathogenesis, inhibitors are useful to prevent and treat AA amyloidosis, serving as tools to investigate the pathogenic mechanism. In this study, we showed that rosmarinic acid (RA), which is a well-known inhibitor of the aggregation of amyloid β (Aβ), displayed inhibitory activity against SAA aggregation in vitro using a microliter-scale high-throughput screening (MSHTS) system with quantum-dot nanoprobes. Therefore, we evaluated the amyloid aggregation inhibitory activity of blood and the deposition of SAA in organs by feeding mice with Melissa officinalis extract (ME) containing RA as an active substance. Interestingly, the inhibitory activity of ME-fed mice sera for SAA and Aβ aggregation, measured with the MSHTS system, was higher than that of the control group. The amount of amyloid deposition in the organs of ME-fed mice was lower than that in the control group, suggesting that the SAA aggregation inhibitory activity of serum is associated with SAA deposition. These results suggest that dietary intake of RA-containing ME enhanced amyloid aggregation inhibitory activity of blood and suppressed SAA deposition in organs. This study also demonstrated that the MSHTS system could be applied to in vitro screening and to monitor comprehensive activity of metabolized foods adsorbed by blood.
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Affiliation(s)
- Xuguang Lin
- Graduate School of Engineering, Muroran Institute of Technology, Muroran 050-8585, Japan; (X.L.); (M.K.); (Y.K.); (U.N.)
| | - Kenichi Watanabe
- Department of Veterinary Medicine, Research Center of Global Agromedicine, Obihiro University of Agriculture and Veterinary Medicine, Obihiro 080-8555, Japan;
| | - Masahiro Kuragano
- Graduate School of Engineering, Muroran Institute of Technology, Muroran 050-8585, Japan; (X.L.); (M.K.); (Y.K.); (U.N.)
| | - Yukina Kurotaki
- Graduate School of Engineering, Muroran Institute of Technology, Muroran 050-8585, Japan; (X.L.); (M.K.); (Y.K.); (U.N.)
| | - Ushio Nakanishi
- Graduate School of Engineering, Muroran Institute of Technology, Muroran 050-8585, Japan; (X.L.); (M.K.); (Y.K.); (U.N.)
- Yamada Science Foundation, Osaka 544-8666, Japan
| | - Kiyotaka Tokuraku
- Graduate School of Engineering, Muroran Institute of Technology, Muroran 050-8585, Japan; (X.L.); (M.K.); (Y.K.); (U.N.)
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43
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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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44
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Suenari K. Editorial to •Trends, burden, and impact of arrhythmia on cardiac amyloid patients: A 16‐year nationwide study from 1999 to 2014•. J Arrhythm 2020; 36:735-736. [PMID: 32782647 PMCID: PMC7411230 DOI: 10.1002/joa3.12388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 06/04/2020] [Indexed: 11/30/2022] Open
Affiliation(s)
- Kazuyoshi Suenari
- Department of Cardiology Hiroshima City Hiroshima Citizens Hospital Hiroshima Japan
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45
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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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46
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Ochi Y, Kubo T, Baba Y, Nakashima Y, Ueda M, Takahashi A, Miyagawa K, Noguchi T, Hirota T, Yamasaki N, Kitaoka H. Prediction of Medium-Term Mortality in Japanese Patients With Wild-Type Transthyretin Amyloidosis. Circ Rep 2020; 2:314-321. [PMID: 33693246 PMCID: PMC7925325 DOI: 10.1253/circrep.cr-20-0031] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background: The prognostic factors in Japanese patients with wild-type transthyretin amyloidosis (ATTRwt) have not been elucidated. Methods and Results: In this study we retrospectively analyzed the clinical characteristics and outcomes of 47 patients with ATTRwt (mean (±SD) age at diagnosis 80.3±4.6 years; 41 males). Fifteen patients died within 2 years of their diagnosis. Receiver operating characteristic and Kaplan-Meier analyses revealed that the best predictors of 2-year mortality were low serum albumin (≤3.75 g/dL), elevated high-sensitivity cardiac troponin T (hs-cTnT; >0.086 ng/mL), and reduced left ventricular ejection fraction (LVEF; <50%). According to the total number of these 3 risk factors, patients were stratified into 4 subgroups: low risk (no risk factors; n=15), intermediate-low risk (1 risk factor; n=15), intermediate-high risk (2 risk factors; n=7), and high risk (3 risk factors; n=10). The estimated 2-year survival rate of patients classified as low risk, intermediate-low risk, intermediate-high risk, and high risk was 93%, 80%, 83%, and 11%, respectively (P<0.001). Conclusions: Low serum albumin, elevated hs-cTnT, and reduced LVEF are associated with a worse prognosis in Japanese patients with ATTRwt. The combination of these factors may be useful for predicting medium-term mortality in patients with ATTRwt.
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Affiliation(s)
- Yuri Ochi
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Toru Kubo
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Yuichi Baba
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Yasuteru Nakashima
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Motoko Ueda
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Asa Takahashi
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Kazuya Miyagawa
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Tatsuya Noguchi
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Takayoshi Hirota
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Naohito Yamasaki
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
| | - Hiroaki Kitaoka
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University Nankoku Japan
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47
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Ramaekers J, Janssens J, Waumans L, Stessens L, Dupont M, Mullens W, Martens P. Indications and diagnostic yield of endomyocardial biopsies for unexplained cardiomyopathy, a single center experience. Acta Cardiol 2020; 75:138-146. [PMID: 30650043 DOI: 10.1080/00015385.2018.1561597] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Background: Endomyocardial biopsies (EMBs) remain the golden standard to diagnose underlying pathophysiologic process in heart failure (HF), when potential therapeutic decisions cannot be made by non-invasive techniques. However, changes in the field of non-invasive diagnostic testing might have an impact on the need for performing an EMB in certain scenarios.Methods: We performed a retrospective analysis of consecutive EMBs performed in a single, non-academic, tertiary-care centre. EMBs were performed between February 2009 and March 2018. Baseline characteristics including non-invasive imaging and hemodynamic profile were assessed. Indications of EMBs were analysed in accordance with the 2007-AHA/ACC/ESC-scientific statement on EMBs.Results: A total of 57 patients (74% male) were included. The overall diagnostic yield was 58%, with a trend towards a higher yield in left-side (64%) versus right-side EMBs (45%; p = .346). The majority of patients (88%) underwent EMBs for a class IIa-recommendation, 9% for a class-I recommendation and the remaining patients for a class IIb-indication. Of the EMBs for a class IIa indication, 82% (n = 47) was for an unexplained restrictive cardiomyopathy, in which 53% (n = 25) revealed a diagnosis (of whom n = 23 patients had amyloidosis). Subtyping of the EMBs with a pathologic diagnosis of amyloidosis revealed that 52% (n = 12) had transthyretin amyloidosis (ATTR) and 43% (n = 10) had light-chain amyloidosis (AL). Overall one major (1.7%) and one minor (1.7%) complication occurred following the EMB-procedure.Conclusions: When following the AHA/ACC/ESC-scientific statement on EMBs, the performance of EMBs had a high diagnostic yield, with acceptable complication rates. However, in patients presenting with an unexplained restricted cardiomyopathy, technetium-labelled bone scanning could offer a non-invasive approach to establishing the diagnosis of ATTR, mitigating the need for EMBs in a subset of patients.
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Affiliation(s)
- Jobbe Ramaekers
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Joyce Janssens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Lise Waumans
- Department of Pathology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Linde Stessens
- Department of Pathology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Matthias Dupont
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Pieter Martens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
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48
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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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49
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Nitsche C, Aschauer S, Kammerlander AA, Schneider M, Poschner T, Duca F, Binder C, Koschutnik M, Stiftinger J, Goliasch G, Siller-Matula J, Winter MP, Anvari-Pirsch A, Andreas M, Geppert A, Beitzke D, Loewe C, Hacker M, Agis H, Kain R, Lang I, Bonderman D, Hengstenberg C, Mascherbauer J. Light-chain and transthyretin cardiac amyloidosis in severe aortic stenosis: prevalence, screening possibilities, and outcome. Eur J Heart Fail 2020; 22:1852-1862. [PMID: 32078212 PMCID: PMC7687139 DOI: 10.1002/ejhf.1756] [Citation(s) in RCA: 87] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2019] [Revised: 01/05/2020] [Accepted: 01/16/2020] [Indexed: 01/15/2023] Open
Abstract
Aims Concomitant cardiac amyloidosis (CA) in severe aortic stenosis (AS) is difficult to recognize, since both conditions are associated with concentric left ventricular thickening. We aimed to assess type, frequency, screening parameters, and prognostic implications of CA in AS. Methods and results A total of 191 consecutive AS patients (81.2 ± 7.4 years; 50.3% female) scheduled for transcatheter aortic valve replacement (TAVR) were prospectively enrolled. Overall, 81.7% underwent complete assessment including echocardiography with strain analysis, electrocardiography (ECG), cardiac magnetic resonance imaging (CMR), 99mTc‐DPD scintigraphy, serum and urine free light chain measurement, and myocardial biopsy in immunoglobulin light chain (AL)‐CA. Voltage/mass ratio (VMR; Sokolow–Lyon index on ECG/left ventricular mass index) and stroke volume index (SVi) were tested as screening parameters. Receiver operating characteristic curve, binary logistic regression, and Kaplan–Meier curve analyses were performed. CA was found in 8.4% of patients (n = 16); 15 had transthyretin (TTR)‐CA and one AL‐CA. While global longitudinal strain by echo did not reliably differentiate AS from CA‐AS [area under the curve (AUC) 0.643], VMR as well as SVi showed good discriminative power (AUC 0.770 and 0.773, respectively), which was comparable to extracellular volume by CMR (AUC 0.756). Also, VMR and SVi were independently associated with CA by multivariate logistic regression analysis (P = 0.016 and P = 0.027, respectively). CA did not significantly affect survival 15.3 ± 7.9 months after TAVR (P = 0.972). Conclusion Both TTR‐ and AL‐CA can accompany severe AS. Parameters solely based on ECG and echocardiography allow for the identification of the majority of CA‐AS. In the present cohort, CA did not significantly worsen prognosis 15.3 months after TAVR.
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Affiliation(s)
- Christian Nitsche
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Stefan Aschauer
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Andreas A Kammerlander
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Matthias Schneider
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Thomas Poschner
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Franz Duca
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Christina Binder
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Matthias Koschutnik
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Julian Stiftinger
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Georg Goliasch
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Jolanta Siller-Matula
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Max-Paul Winter
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Anahit Anvari-Pirsch
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | - Alexander Geppert
- Department of Internal Medicine III, Division of Cardiology, Wilhelminenspital, Vienna, Austria
| | - Dietrich Beitzke
- Department of Cardiovascular and Interventional Radiology, Department of Radiology, Medical University of Vienna, Vienna, Austria
| | - Christian Loewe
- Department of Cardiovascular and Interventional Radiology, Department of Radiology, Medical University of Vienna, Vienna, Austria
| | - Marcus Hacker
- Department of Nuclear Medicine, Medical University of Vienna, Vienna, Austria
| | - Hermine Agis
- Division of Oncology, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria
| | - Renate Kain
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Irene Lang
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Diana Bonderman
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Christian Hengstenberg
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Julia Mascherbauer
- Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
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50
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Diagnosis of genetic amyloidosis through the analysis of transthyretin gene mutation using high-resolution melting. Int J Cardiol 2020; 301:220-225. [PMID: 31740141 DOI: 10.1016/j.ijcard.2019.10.028] [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] [Received: 03/09/2019] [Revised: 10/09/2019] [Accepted: 10/15/2019] [Indexed: 01/22/2023]
Abstract
Transthyretin amyloidosis can be either the wild-type (ATTR-wt) or the hereditary form (ATTR-m) with autosomal dominant inheritance. ATTR seems to be an underdiagnosed disease, despite now being recognized as one of the most frequent causes of heart failure (HF) with preserved ejection fraction. The confirmation of diagnosis includes a genetic analysis as a critical step to distinguish between ATTR-wt and hereditary amyloidosis. The present study aimed to evaluate the potential application of High-Resolution Melting (HRM) analysis for identifying gene mutations in patients with suspected ATTR-m. We have adapted and validated the use of HRM for TTR mutations. We, therefore, sequenced the TTR gene and used HRM in a group of 134 patients suspected of suffering from amyloidosis. Seven patients were diagnosed with mutations in the TTR gene (p.Glu74Gln, heterozygous p.Val142Ile, and homozygous p.Val142Ile). HRM is capable of clearly detecting these TTR mutations, including the heterozygous and homozygous variants. The results show a 100% correlation between the HRM study and TTR sequencing. These results support future studies of applying HRM analysis as a diagnostic approach for ATTR-m, mainly for epidemiological studies.
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