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Scheel PJ, Mukherjee M, Hays AG, Vaishnav J. Multimodality Imaging in the Evaluation and Prognostication of Cardiac Amyloidosis. Front Cardiovasc Med 2022; 9:787618. [PMID: 35402557 PMCID: PMC8989413 DOI: 10.3389/fcvm.2022.787618] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 02/14/2022] [Indexed: 11/13/2022] Open
Abstract
Cardiac amyloidosis (CA) is an infiltrative cardiomyopathy resulting from deposition of misfolded immunoglobulin light chains (AL-CA) or transthyretin (ATTR-CA) proteins in the myocardium. Survival varies between the different subtypes of amyloidosis and degree of cardiac involvement, but accurate diagnosis is essential to ensure initiation of therapeutic interventions that may slow or potentially prevent morbidity and mortality in these patients. As there are now effective treatment options for CA, identifying underlying disease pathogenesis is crucial and can be guided by multimodality imaging techniques such as echocardiography, magnetic resonance imaging, and nuclear scanning modalities. However, as use of cardiac imaging is becoming more widespread, understanding optimal applications and potential shortcomings is increasingly important. Additionally, certain imaging modalities can provide prognostic information and may affect treatment planning. In patients whom imaging remains non-diagnostic, tissue biopsy, specifically endomyocardial biopsy, continues to play an essential role and can facilitate accurate and timely diagnosis such that appropriate treatment can be started. In this review, we examine the multimodality imaging approach to the diagnosis of CA with particular emphasis on the prognostic utility and limitations of each imaging modality. We also discuss how imaging can guide the decision to pursue tissue biopsy for timely diagnosis of CA.
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Palmiero G, Vetrano E, Rubino M, Monda E, Dongiglio F, Lioncino M, Di Fraia F, Caiazza M, Verrillo F, Capodicasa L, Cerciello G, Manganelli F, Catalano M, D'Arienzo D, De Rimini ML, Ascione R, Golino P, Caso P, Ascione L, Limongelli G. The Role of New Imaging Technologies in the Diagnosis of Cardiac Amyloidosis. Heart Fail Clin 2021; 18:61-72. [PMID: 34776084 DOI: 10.1016/j.hfc.2021.07.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Cardiac amyloidosis is an infiltrative disorder caused by transthyretin or immunoglobulin free light-chain deposition, which determines clinical disease with similar phenotype but different time course, prognosis and therapy. Multimodality imaging is the cornerstone for disease diagnosis and management. Multimodality imaging has revolutionized the approach to the disease favoring its awareness and simplifying its diagnosis, especially in ATTR cardiac amyloidosis. This describes the different imaging tools, from the traditional to the more novel ones, and highlights the different approach in each different setting (prognosis, subtyping, prognosis, monitoring disease progression, and response to therapy).
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Affiliation(s)
- Giuseppe Palmiero
- Department of Cardiology, AORN Ospedale dei Colli - Monaldi Hospital, via Leonardo Bianchi SNC, 80131 Naples, Italy; Inherited and Rare Cardiovascular Diseases Unit, AORN Ospedale dei Colli - Monaldi Hospital, via Leonardo Bianchi SNC, 80131 Naples, Italy.
| | - Erica Vetrano
- Inherited and Rare Cardiovascular Diseases Unit, AORN Ospedale dei Colli - Monaldi Hospital, via Leonardo Bianchi SNC, 80131 Naples, Italy
| | - Marta Rubino
- Inherited and Rare Cardiovascular Diseases Unit, AORN Ospedale dei Colli - Monaldi Hospital, via Leonardo Bianchi SNC, 80131 Naples, Italy
| | - Emanuele Monda
- Inherited and Rare Cardiovascular Diseases Unit, AORN Ospedale dei Colli - Monaldi Hospital, via Leonardo Bianchi SNC, 80131 Naples, Italy
| | - Francesca Dongiglio
- Inherited and Rare Cardiovascular Diseases Unit, AORN Ospedale dei Colli - Monaldi Hospital, via Leonardo Bianchi SNC, 80131 Naples, Italy
| | - Michele Lioncino
- Inherited and Rare Cardiovascular Diseases Unit, AORN Ospedale dei Colli - Monaldi Hospital, via Leonardo Bianchi SNC, 80131 Naples, Italy
| | - Francesco Di Fraia
- Inherited and Rare Cardiovascular Diseases Unit, AORN Ospedale dei Colli - Monaldi Hospital, via Leonardo Bianchi SNC, 80131 Naples, Italy
| | - Martina Caiazza
- Inherited and Rare Cardiovascular Diseases Unit, AORN Ospedale dei Colli - Monaldi Hospital, via Leonardo Bianchi SNC, 80131 Naples, Italy
| | - Federica Verrillo
- Inherited and Rare Cardiovascular Diseases Unit, AORN Ospedale dei Colli - Monaldi Hospital, via Leonardo Bianchi SNC, 80131 Naples, Italy
| | - Laura Capodicasa
- Inherited and Rare Cardiovascular Diseases Unit, AORN Ospedale dei Colli - Monaldi Hospital, via Leonardo Bianchi SNC, 80131 Naples, Italy
| | - Giuseppe Cerciello
- Haematology Unit (Building n. 2), Department of Clinical Medicine and Surgery, AOU Policlinico "Federico II", via Sergio Pansini 5, 80131 Naples, Italy
| | - Fiore Manganelli
- Neurology Unit (Building n. 17), Department of Neurosciences, Reproductive Medicine and Odontostomatology, AOU Policlinico "Federico II", via Sergio Pansini 5, 80131 Naples, Italy
| | - Mara Catalano
- Department of Nuclear Imaging, AORN Cardarelli Hospital, via Antonio Cardarelli 9, 80131 Naples, Italy
| | - Davide D'Arienzo
- Department of Nuclear Medicine, AORN Ospedale dei Colli - Monaldi Hospital, via Leonardo Bianchi SNC, 80131 Naples, Italy
| | - Maria Luisa De Rimini
- Department of Nuclear Medicine, AORN Ospedale dei Colli - Monaldi Hospital, via Leonardo Bianchi SNC, 80131 Naples, Italy
| | - Raffaele Ascione
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy
| | - Paolo Golino
- Department of Cardiology, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Pio Caso
- Department of Cardiology, AORN Ospedale dei Colli - Monaldi Hospital, via Leonardo Bianchi SNC, 80131 Naples, Italy
| | - Luigi Ascione
- Department of Cardiology, AORN Ospedale dei Colli - Monaldi Hospital, via Leonardo Bianchi SNC, 80131 Naples, Italy
| | - Giuseppe Limongelli
- Inherited and Rare Cardiovascular Diseases Unit, AORN Ospedale dei Colli - Monaldi Hospital, via Leonardo Bianchi SNC, 80131 Naples, Italy; Institute of Cardiovascular Sciences, University College of London and St. Bartholomew's Hospital, London, UK
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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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Cicco S, Solimando AG, Buono R, Susca N, Inglese G, Melaccio A, Prete M, Ria R, Racanelli V, Vacca A. Right Heart Changes Impact on Clinical Phenotype of Amyloid Cardiac Involvement: A Single Centre Study. Life (Basel) 2020; 10:life10100247. [PMID: 33081052 PMCID: PMC7603245 DOI: 10.3390/life10100247] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Revised: 10/12/2020] [Accepted: 10/16/2020] [Indexed: 12/18/2022] Open
Abstract
Amyloidosis is due to deposition of an excessive amount of protein in many parenchymal tissues, including myocardium. The onset of cardiac Amyloidosis (CA) is an inauspicious prognostic factor, which can lead to sudden death. We retrospectively analyzed 135 patients with systemic amyloidosis, admitted to our ward between 1981 and 2019. Among them, 54 patients (46.30% F/53.70% M, aged 63.95 ± 12.82) presented CA at baseline. In 53 patients, it was associated with a multiorgan involvement, while in one there was a primary myocardial deposition. As a control group, we enrolled 81 patients (49.30% F/50.70% M, aged 58.33 ± 15.65) who did not meet the criteria for CA. In 44/54 of patients CA was associated with AL, 5/54 with AA and 3/54 of patients with ATTR, and in 1/54 AL was related to hemodialysis and in 1/54 to Gel-Amyloidosis. The most common AL type was IgG (28/44); less frequent forms were either IgA (7/44) or IgD (2/44), while seven patients had a λ free light chain form. The 32 AL with complete Ig were 31 λ-chain and just one k-chain. CA patients presented normal BP (SBP 118.0 ± 8.4 mmHg; DBP 73.8 ± 4.9 mmHg), while those with nCA had an increased proteinuria (p = 0.02). TnI and NT-proBNP were significantly increased compared to nCA (p = 0.031 and p = 0.047, respectively). In CA patients we found an increased LDH compared to nCA (p = 0.0011). CA patients were also found to have an increased interventricular septum thickness compared to nCA (p = 0.002), a decreased Ejection Fraction % (p = 0.0018) and Doppler velocity E/e’ ratio (p = 0.0095). Moreover, CA patients had an enhanced right atrium area (p = 0.0179), right ventricle basal diameter (p = 0.0112) and wall thickness (p = 0.0471) compared to nCA, and an increased inferior cava vein diameter (p = 0.0495) as well. TAPSE was the method chosen to evaluate systolic function of the right heart. In CA subjects very poor TAPSE levels were found compared to nCA patients (p = 0.0495). Additionally, we found a significant positive correlation between TAPSE and lymphocyte count (r = 0.47; p = 0.031) as well as Gamma globulins (r = 0.43, p = 0.033), Monoclonal components (r = 0.72; p = 0.047) and IgG values (r = 0.62, p = 0.018). Conversely, a significant negative correlation with LDH (r = −0.57, p = 0.005), IVS (r = −0.51, p = 0.008) and diastolic function evaluated as E/e’ (r = −0.60, p = 0.003) were verified. CA patients had very poor survival rates compared to controls (30 vs. 66 months in CA vs. nCA, respectively, p = 0.15). Mean survival of CA individuals was worse also when stratified according to NT-proBNP levels, using 2500 pg/mL as class boundary (174 vs. 5.5 months, for patients with lower vs. higher values than the median, respectively p = 0.013). In much the same way, a decreased right heart systolic function was correlated with a worse prognosis (18.0 months median survival, not reached in subjects with lower values than 18 mm, p = 0.0186). Finally, our data highlight the potential prognostic and predictive value of right heart alterations characterizing amyloidosis, as a novel clinical parameter correlated to increased LDH and immunoglobulins levels. Overall, we confirm the clinical relevance of cardiac involvement suggests that right heart evaluation may be considered as a new marker for clinical risk stratification in patients with amyloidosis.
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Affiliation(s)
- Sebastiano Cicco
- Unit of Internal Medicine “Guido Baccelli”, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Piazza Giulio Cesare 11, I-70124 Bari, Italy; (S.C.); (A.G.S.); (R.B.); (N.S.); (G.I.); (A.M.); (M.P.); (R.R.); (V.R.)
- Internal Medicine Department, AUO Policlinico Ospedali Riuniti, Viale L. Pinto, I-71122 Foggia, Italy
| | - Antonio Giovanni Solimando
- Unit of Internal Medicine “Guido Baccelli”, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Piazza Giulio Cesare 11, I-70124 Bari, Italy; (S.C.); (A.G.S.); (R.B.); (N.S.); (G.I.); (A.M.); (M.P.); (R.R.); (V.R.)
- IRCCS Istituto Tumori “Giovanni Paolo II” of Bari, Viale Orazio Flacco 65, I-70124 Bari, Italy
| | - Roberta Buono
- Unit of Internal Medicine “Guido Baccelli”, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Piazza Giulio Cesare 11, I-70124 Bari, Italy; (S.C.); (A.G.S.); (R.B.); (N.S.); (G.I.); (A.M.); (M.P.); (R.R.); (V.R.)
| | - Nicola Susca
- Unit of Internal Medicine “Guido Baccelli”, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Piazza Giulio Cesare 11, I-70124 Bari, Italy; (S.C.); (A.G.S.); (R.B.); (N.S.); (G.I.); (A.M.); (M.P.); (R.R.); (V.R.)
| | - Gianfranco Inglese
- Unit of Internal Medicine “Guido Baccelli”, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Piazza Giulio Cesare 11, I-70124 Bari, Italy; (S.C.); (A.G.S.); (R.B.); (N.S.); (G.I.); (A.M.); (M.P.); (R.R.); (V.R.)
| | - Assunta Melaccio
- Unit of Internal Medicine “Guido Baccelli”, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Piazza Giulio Cesare 11, I-70124 Bari, Italy; (S.C.); (A.G.S.); (R.B.); (N.S.); (G.I.); (A.M.); (M.P.); (R.R.); (V.R.)
| | - Marcella Prete
- Unit of Internal Medicine “Guido Baccelli”, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Piazza Giulio Cesare 11, I-70124 Bari, Italy; (S.C.); (A.G.S.); (R.B.); (N.S.); (G.I.); (A.M.); (M.P.); (R.R.); (V.R.)
| | - Roberto Ria
- Unit of Internal Medicine “Guido Baccelli”, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Piazza Giulio Cesare 11, I-70124 Bari, Italy; (S.C.); (A.G.S.); (R.B.); (N.S.); (G.I.); (A.M.); (M.P.); (R.R.); (V.R.)
| | - Vito Racanelli
- Unit of Internal Medicine “Guido Baccelli”, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Piazza Giulio Cesare 11, I-70124 Bari, Italy; (S.C.); (A.G.S.); (R.B.); (N.S.); (G.I.); (A.M.); (M.P.); (R.R.); (V.R.)
| | - Angelo Vacca
- Unit of Internal Medicine “Guido Baccelli”, Department of Biomedical Sciences and Human Oncology, University of Bari Aldo Moro Medical School, Piazza Giulio Cesare 11, I-70124 Bari, Italy; (S.C.); (A.G.S.); (R.B.); (N.S.); (G.I.); (A.M.); (M.P.); (R.R.); (V.R.)
- Correspondence:
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Jung HN, Kim SM, Lee JH, Kim Y, Lee SC, Jeon ES, Yong HS, Choe YH. Comparison of tissue tracking assessment by cardiovascular magnetic resonance for cardiac amyloidosis and hypertrophic cardiomyopathy. Acta Radiol 2020; 61:885-893. [PMID: 31684748 DOI: 10.1177/0284185119883714] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Administration of gadolinium-contrast can cause problems in cardiac amyloidosis (CA) patients with impaired renal function. PURPOSE To compare patterns of cardiovascular magnetic resonance tissue tracking (CMR-TT) for CA and hypertrophic cardiomyopathy (HCM) and to assess the feasibility of CMR-TT to distinguish between these diseases without administration of gadolinium-contrast. MATERIAL AND METHODS Included were 54 patients with biopsy-proven CA, 40 patients with HCM, and 30 healthy people. We calculated strain ratio of apex to base (SRAB) in the left ventricle (LV) using radial (R), circumferential (C), and longitudinal (L) strain from CMR-TT. The LV ejection fraction (LVEF) and the ratio of septal to posterior wall at basal level were also calculated. Late gadolinium enhancement (LGE) image analysis was performed for differential diagnosis. Area under the receiver operating characteristic curve (AUC) comparisons were used. RESULTS All SRAB values were significantly different between CA and HCM (all P < 0.001). AUC values for parameters were 0.806 for LVEF, 0.815 for ratio of wall thickness, 0.944 for the LGE pattern, 0.898 for SRABR, 0.880 for SRABC, and 0.805 for SRABL. AUCs for the LGE pattern were significantly higher than for LVEF, ratio of wall thickness and SRABL (all P < 0.008). No significant differences were seen between AUCs for the LGE pattern, SRABR, and SRABC (all P > 0.109). CONCLUSION SRABR and SRABC were reliable parameters for distinguishing between CA and HCM.
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Affiliation(s)
- Hye Na Jung
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Current affiliation: Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Sung Mok Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Cardiovascular Imaging Center, Heart Vascular and Stroke Institute, Samsung Medical Center, Seoul, Republic of Korea
| | - Jeong Hyun Lee
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yiseul Kim
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Sang-Chol Lee
- Division of Cardiology, Department of Medicine, Cardiac and Vascular Center, Samsung Medical Center, Seoul, Republic of Korea
| | - Eun-Seok Jeon
- Division of Cardiology, Department of Medicine, Cardiac and Vascular Center, Samsung Medical Center, Seoul, Republic of Korea
| | - Hwan Seok Yong
- Current affiliation: Department of Radiology, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Yeon Hyeon Choe
- Department of Radiology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
- Cardiovascular Imaging Center, Heart Vascular and Stroke Institute, Samsung Medical Center, Seoul, Republic of Korea
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Abstract
PURPOSE OF REVIEW The aim is to provide a description of the most important echocardiographic features in systemic amyloidosis. RECENT FINDINGS Amyloidosis is a heterogeneous group of multisystem disorders, characterized by an extracellular deposition of amyloid fibrils. Several imaging tests are available for the diagnosis; however, echocardiography is the cornerstone of the non-invasive imaging modality for cardiac amyloidosis. So far, little is known about the diagnosis of cardiac amyloidosis through imaging modalities. We summarized the most important echocardiographic findings in cardiac amyloidosis. Hence, we offered a systematic report of the diagnostic performance of cardiac amyloidosis using echocardiography.
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Fikrle M, Palecek T, Marek J, Kuchynka P, Linhart A. Simplified apical four-chamber view evaluation of relative apical sparing of longitudinal strain in diagnosing AL amyloid cardiomyopathy. Echocardiography 2018; 35:1764-1771. [PMID: 30225879 DOI: 10.1111/echo.14132] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Revised: 07/20/2018] [Accepted: 08/05/2018] [Indexed: 01/20/2023] Open
Abstract
AIM OF THE STUDY To assess the diagnostic utility of a simplified approach to relative apical sparing of longitudinal strain (RAS LS) using only an apical four-chamber view (A4C) in patients with AL amyloid cardiomyopathy (ALAC). METHODS We retrospectively evaluated echocardiographic recordings of 20 patients with ALAC, 20 patients with Fabry disease-related cardiomyopathy (FD), and 20 patients with concentric hypertensive left ventricular hypertrophy (HLVH) matched for mean LV mean thickness. Peak segmental LS values of the interventricular septum and lateral LV wall were measured in the A4C using two-dimensional speckle-tracking echocardiography. RAS LS was calculated as average apical LS/(average basal LS + average midventricular LS). RESULTS Relative apical sparing of longitudinal strain values in patients with ALAC (1.23 ± 0.64) were significantly higher than those in FD patients (0.75 ± 0.19, P < 0.05) as well as in individuals with HLVH (0.75 ± 0.23, P < 0.05), but with a significant overlap. The optimal RAS LS value differentiating ALAC from FD and HLVH with 70% sensitivity and 75% specificity was 0.88 (AUC 0.79). In multivariate modeling, RAS LS was significantly additive to traditional predictors of ALAC (low QRS voltage and pseudoinfarct ECG patterns, pericardial effusion, E/e' ratio, E-wave deceleration time; P < 0.05 for all models). CONCLUSIONS Simplified RAS LS evaluation represents an attractive approach for diagnostics of ALAC. However, because of considerable overlap with other disorders with hypertrophic phenotype, the analysis of RAS LS in the A4C should be combined with other traditional echocardiographic and ECG predictors in differentiating ALAC from other forms of concentric LV wall thickening.
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Affiliation(s)
- Michal Fikrle
- 2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Tomas Palecek
- 2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Josef Marek
- 2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Petr Kuchynka
- 2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
| | - Ales Linhart
- 2nd Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Prague, Czech Republic
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Ono K, Ishimaru G, Hayashi M, Bae Y, Ito T, Izumo T, Murata K. The Imaging Diagnosis of Less Advanced Cases of Cardiac Amyloidosis: The Relative Apical Sparing Pattern. Intern Med 2017; 56:315-319. [PMID: 28154276 PMCID: PMC5348456 DOI: 10.2169/internalmedicine.56.7610] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
An early diagnosis is important for improving the prognosis of cardiac amyloidosis (CA). We herein describe the utility of two-dimensional speckle tracking echocardiography (2-D STE) in diagnosing CA at a less advanced stage. A 63-year-old woman with exertional dyspnea was suspected of having CA based on her echocardiographic and electrocardiographic findings. A myocardial biopsy was negative for amyloid deposits, while the relative apical sparing pattern was detected on 2-D STE, which was highly suggestive of CA. Chemotherapy was initiated as a treatment for CA, and the patient's symptoms were immediately relieved. Thereafter, amyloid deposits were detected in a skin biopsy specimen.
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Affiliation(s)
- Koya Ono
- Department of Hematology, Soka Municipal Hospital, Japan
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9
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Causes and Consequences of Longitudinal LV Dysfunction Assessed by 2D Strain Echocardiography in Cardiac Amyloidosis. JACC Cardiovasc Imaging 2016; 9:126-38. [PMID: 26777222 DOI: 10.1016/j.jcmg.2015.05.014] [Citation(s) in RCA: 135] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2015] [Revised: 04/23/2015] [Accepted: 05/14/2015] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The aim of this study was to compare left ventricular longitudinal strain (LS) evaluated by 2-dimensional echocardiography with cardiac magnetic resonance (CMR) in cardiac amyloidosis (CA), establish correlations between histological and imaging findings, and assess the prognostic usefulness of LS measurement and CMR. BACKGROUND CA is a condition with a poor prognosis due chiefly to 3 forms of amyloidosis: light-chain amyloidosis (AL), hereditary transthyretin (M-TTR), and wild-type transthyretin (WT-TTR). Two-dimensional echocardiography measurement of LS has been reported to detect early left ventricular systolic dysfunction. The pathophysiological underpinnings, regional distribution, and prognostic significance of LS in CA are unclear. METHODS All patients underwent echocardiography, and 53 underwent CMR. The native hearts of the 3 patients who received heart transplants were subjected to histological examination. For each of the 17 left ventricular segments in the American Heart Association model, we evaluated LS, late gadolinium enhancement (LGE) by CMR, and cardiac amyloid deposition. Univariate and multivariate analyses were performed at 6 months to identify variables associated with major adverse cardiac events (MACE). RESULTS We studied 79 patients with CA; 26 had AL, 36 M-TTR, and 17 WT-TTR. Mean LS was -10 ± 4%. Both LS and amyloid deposits showed a basal-to-apical gradient. The mean LS and number of segments with LGE were similar across the 3 CA types. LS correlated with LGE and amyloid burden (r = 0.72). LGE was seen in the 6 basal segments in all WT-TTR patients. During the median follow-up of 11 months (range 4 to 17 months), 36 (46%) patients experienced MACE. Independent predictors of MACE were apical LS (cutoff, -14.5%), N-terminal pro-B-type natriuretic peptide (cutoff, 4,000 ng/l), and New York Heart Association functional class III to IV heart failure. CONCLUSIONS Basal-to-apical LS abnormalities are similar across CA types and reflect the amyloid burden. Apical LS independently predicts MACE.
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Cacciapuoti F. The role of echocardiography in the non-invasive diagnosis of cardiac amyloidosis. J Echocardiogr 2015; 13:84-9. [PMID: 26184746 DOI: 10.1007/s12574-015-0249-1] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2015] [Revised: 06/13/2015] [Accepted: 06/20/2015] [Indexed: 11/28/2022]
Abstract
INTRODUCTION The diagnosis of cardiac amyloidosis (CA) is usually performed by endomyocardial biopsy; however, possible sampling errors and procedural risks such as cardiac tamponade, malignant arrhythmias and bleeding risk, limit its use. Therefore, a non-invasive diagnostic method appears to be necessary. MATERIALS AND METHODS Echocardiography plays an important role in this need. Conventional two-dimensional echocardiography appears able to detect some specific and distinguishing signs of cardiac amyloid infiltration. RESULTS AND CONCLUSIONS Of these, thickened right and left ventricular (LV) myocardium, normal or small LV cavity size in contrast to enlarged biatrial cavities, diffuse hyper-refractile 'granular sparkling' appearance and 'mismatch' ECG/ECHO are the most specific findings. The magnitude of cyclic variation recorded with integrated backscatter reflects structural changes in the myocardium. In patients with CA, this magnitude is reduced because myocardial amyloid infiltration is characterized by a reduction of number of "contractile" fibers. Other informations concerning LV dysfunction CA-related can be obtained by Tei index. Finally, new echocardiographic imaging modalities, such as tissue Doppler, Doppler-based strain, speckle tracking imaging and three-dimensional echocardiography, can provide some findings regarding the preclinical stages of LV dysfunction when other echocardiographic measurements are showing normal; however, these are unable to provide a non-invasive diagnosis of cardiac amyloidosis.
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Affiliation(s)
- Federico Cacciapuoti
- Department of Internal Medicine and Geriatry, Second University of Naples, Piazza L. Miraglia 2, 80100, Naples, Italy,
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Liu D, Hu K, Niemann M, Herrmann S, Cikes M, Störk S, Gaudron PD, Knop S, Ertl G, Bijnens B, Weidemann F. Effect of Combined Systolic and Diastolic Functional Parameter Assessment for Differentiation of Cardiac Amyloidosis From Other Causes of Concentric Left Ventricular Hypertrophy. Circ Cardiovasc Imaging 2013; 6:1066-72. [DOI: 10.1161/circimaging.113.000683] [Citation(s) in RCA: 126] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Dan Liu
- From the Department of Internal Medicine I (D.L., K.H., M.N., S.H., S.S., P.D.G., G.E., F.W.), Comprehensive Heart Failure Center (D.L., K.H., M.N., S.H., S.S., P.D.G., G.E., F.W.), and Department of Internal Medicine II (S.K.), University of Würzburg, Würzburg, Germany; Department of Cardiovascular Diseases, University Hospital Center Zagreb and School of Medicine, University of Zagreb, Zagreb, Croatia (M.C.); ICREA–Universitat Pompeu Fabra, Barcelona, Spain (B.B.); and Department of Cardiovascular
| | - Kai Hu
- From the Department of Internal Medicine I (D.L., K.H., M.N., S.H., S.S., P.D.G., G.E., F.W.), Comprehensive Heart Failure Center (D.L., K.H., M.N., S.H., S.S., P.D.G., G.E., F.W.), and Department of Internal Medicine II (S.K.), University of Würzburg, Würzburg, Germany; Department of Cardiovascular Diseases, University Hospital Center Zagreb and School of Medicine, University of Zagreb, Zagreb, Croatia (M.C.); ICREA–Universitat Pompeu Fabra, Barcelona, Spain (B.B.); and Department of Cardiovascular
| | - Markus Niemann
- From the Department of Internal Medicine I (D.L., K.H., M.N., S.H., S.S., P.D.G., G.E., F.W.), Comprehensive Heart Failure Center (D.L., K.H., M.N., S.H., S.S., P.D.G., G.E., F.W.), and Department of Internal Medicine II (S.K.), University of Würzburg, Würzburg, Germany; Department of Cardiovascular Diseases, University Hospital Center Zagreb and School of Medicine, University of Zagreb, Zagreb, Croatia (M.C.); ICREA–Universitat Pompeu Fabra, Barcelona, Spain (B.B.); and Department of Cardiovascular
| | - Sebastian Herrmann
- From the Department of Internal Medicine I (D.L., K.H., M.N., S.H., S.S., P.D.G., G.E., F.W.), Comprehensive Heart Failure Center (D.L., K.H., M.N., S.H., S.S., P.D.G., G.E., F.W.), and Department of Internal Medicine II (S.K.), University of Würzburg, Würzburg, Germany; Department of Cardiovascular Diseases, University Hospital Center Zagreb and School of Medicine, University of Zagreb, Zagreb, Croatia (M.C.); ICREA–Universitat Pompeu Fabra, Barcelona, Spain (B.B.); and Department of Cardiovascular
| | - Maja Cikes
- From the Department of Internal Medicine I (D.L., K.H., M.N., S.H., S.S., P.D.G., G.E., F.W.), Comprehensive Heart Failure Center (D.L., K.H., M.N., S.H., S.S., P.D.G., G.E., F.W.), and Department of Internal Medicine II (S.K.), University of Würzburg, Würzburg, Germany; Department of Cardiovascular Diseases, University Hospital Center Zagreb and School of Medicine, University of Zagreb, Zagreb, Croatia (M.C.); ICREA–Universitat Pompeu Fabra, Barcelona, Spain (B.B.); and Department of Cardiovascular
| | - Stefan Störk
- From the Department of Internal Medicine I (D.L., K.H., M.N., S.H., S.S., P.D.G., G.E., F.W.), Comprehensive Heart Failure Center (D.L., K.H., M.N., S.H., S.S., P.D.G., G.E., F.W.), and Department of Internal Medicine II (S.K.), University of Würzburg, Würzburg, Germany; Department of Cardiovascular Diseases, University Hospital Center Zagreb and School of Medicine, University of Zagreb, Zagreb, Croatia (M.C.); ICREA–Universitat Pompeu Fabra, Barcelona, Spain (B.B.); and Department of Cardiovascular
| | - Philipp Daniel Gaudron
- From the Department of Internal Medicine I (D.L., K.H., M.N., S.H., S.S., P.D.G., G.E., F.W.), Comprehensive Heart Failure Center (D.L., K.H., M.N., S.H., S.S., P.D.G., G.E., F.W.), and Department of Internal Medicine II (S.K.), University of Würzburg, Würzburg, Germany; Department of Cardiovascular Diseases, University Hospital Center Zagreb and School of Medicine, University of Zagreb, Zagreb, Croatia (M.C.); ICREA–Universitat Pompeu Fabra, Barcelona, Spain (B.B.); and Department of Cardiovascular
| | - Stefan Knop
- From the Department of Internal Medicine I (D.L., K.H., M.N., S.H., S.S., P.D.G., G.E., F.W.), Comprehensive Heart Failure Center (D.L., K.H., M.N., S.H., S.S., P.D.G., G.E., F.W.), and Department of Internal Medicine II (S.K.), University of Würzburg, Würzburg, Germany; Department of Cardiovascular Diseases, University Hospital Center Zagreb and School of Medicine, University of Zagreb, Zagreb, Croatia (M.C.); ICREA–Universitat Pompeu Fabra, Barcelona, Spain (B.B.); and Department of Cardiovascular
| | - Georg Ertl
- From the Department of Internal Medicine I (D.L., K.H., M.N., S.H., S.S., P.D.G., G.E., F.W.), Comprehensive Heart Failure Center (D.L., K.H., M.N., S.H., S.S., P.D.G., G.E., F.W.), and Department of Internal Medicine II (S.K.), University of Würzburg, Würzburg, Germany; Department of Cardiovascular Diseases, University Hospital Center Zagreb and School of Medicine, University of Zagreb, Zagreb, Croatia (M.C.); ICREA–Universitat Pompeu Fabra, Barcelona, Spain (B.B.); and Department of Cardiovascular
| | - Bart Bijnens
- From the Department of Internal Medicine I (D.L., K.H., M.N., S.H., S.S., P.D.G., G.E., F.W.), Comprehensive Heart Failure Center (D.L., K.H., M.N., S.H., S.S., P.D.G., G.E., F.W.), and Department of Internal Medicine II (S.K.), University of Würzburg, Würzburg, Germany; Department of Cardiovascular Diseases, University Hospital Center Zagreb and School of Medicine, University of Zagreb, Zagreb, Croatia (M.C.); ICREA–Universitat Pompeu Fabra, Barcelona, Spain (B.B.); and Department of Cardiovascular
| | - Frank Weidemann
- From the Department of Internal Medicine I (D.L., K.H., M.N., S.H., S.S., P.D.G., G.E., F.W.), Comprehensive Heart Failure Center (D.L., K.H., M.N., S.H., S.S., P.D.G., G.E., F.W.), and Department of Internal Medicine II (S.K.), University of Würzburg, Würzburg, Germany; Department of Cardiovascular Diseases, University Hospital Center Zagreb and School of Medicine, University of Zagreb, Zagreb, Croatia (M.C.); ICREA–Universitat Pompeu Fabra, Barcelona, Spain (B.B.); and Department of Cardiovascular
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Baccouche H, Maunz M, Beck T, Gaa E, Banzhaf M, Knayer U, Fogarassy P, Beyer M. Differentiating cardiac amyloidosis and hypertrophic cardiomyopathy by use of three-dimensional speckle tracking echocardiography. Echocardiography 2012; 29:668-77. [PMID: 22486396 DOI: 10.1111/j.1540-8175.2012.01680.x] [Citation(s) in RCA: 85] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION Cardiac amyloidosis (CA) and hypertrophic cardiomyopathy (HCM) are important differential diagnosis of left ventricular hypertrophy. The aim of this study was to investigate if three-dimensional (3D) speckle tracking-derived functional parameters enabled differentiation of CA and HCM by a disease-specific pattern. METHODS Twelve patients with CA and 12 patients with HCM were included. CA and HCM were diagnosed by contrast-enhanced cardiovascular magnetic resonance (CMR). Three-dimensional speckle tracking echocardiography with wall motion analysis was performed for strain (radial [RS(%)], longitudinal [LS (-%)], and circumferential [CS (-%)]), rotation (ROT [degree]), and twist (TWT [degree]). Intergroup comparison included normalized values from 49 healthy volunteers. RESULTS Averaged RS, LS, CS, ROT, and TWT were investigated at basal, midventricular, and apical levels. With some exceptions, 3D speckle tracking function parameters were mostly lower in the HCM and minimal in the CA group as compared to controls. Comparing CA and HCM, basal RS was significantly reduced in patients with amyloidosis (7.5 ± 19.7 vs. 22.3 ± 22.7; P < 0.0001), furthermore the "physiological" gradient of basoapically decreasing RS, which was reduced, but still preserved in HCM, showed a clear "inverse pattern" in patients with amyloidosis, comprising a gradual increase from base to apex. Correlation analysis of 3D speckle tracking function and CMR late gadolinium enhancement (LGE) revealed high inverse correlation of RS and LGE in CA (r =-0.82) and only mild correlation in HCM, followed by CS as second best parameter. An increasing/decreasing basoapical RS gradient yielded a sensitivity of 83% versus the CMR-derived diagnosis "CA" and "HCM." CONCLUSIONS Three-dimensional speckle tracking echocardiography demonstrated significant differences in CA and HCM. The basoapical RS gradient displayed oppositional characteristics in CA and HCM, suggesting a "function-pattern-based" differentiation of amyloidosis and HCM.
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Affiliation(s)
- Hannibal Baccouche
- Department of Medicine II, Hospital Kirchheim/Teck, Kreiskliniken Esslingen, Germany.
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